HomeMy WebLinkAboutApplicationGarfield County
Public Heølth
L95 w. L4th street
Rifle, CO 81"650
(e7ol62s-5200
2014 Blake Avenue
Glenwood Springs, CO 81601
(s70) 94s-6614
OWTS PERMIT APPLICATION
TYPE OF SYSTEM CONSTRUSTION
E New lnstallation tr Alteration n Repair
BUITDING USAGE TYPE
Ë Dwelling E Transient Use El Comm./lndustrial n Non-Domestic
E Other Describe
INVOIVED PARTIES
Property Owner: Kay Crook and Bernard Crook Phone:1303 ì crq-nzlc
Mailing Add PO Box 1174 Rifle, CO 81650
Email Address3 k¡yrrnok@mqn .nm
1970 ¡ 216-4698
Mailing Address: 2652 Eagle Ridge Ct.Grand Junction, CO 81503
Email Address:mrdirt16@aol.com
(97O ) r
Mailing Address 2789 Riverside Parkway Grand Junction, Colorado 81501
Email Address¡ lnfo@huddlestonberry.com
PROJECT TOCATION AND DESCRIPTION
Job Address:TBD Hwv 6. Silt, CO 8L652
Assessol,s Parcel Numbs¡; 217902400546 Sub. 2 Lot-Block
Building or Service Type: Residential - duplex fBedrooms: 4 Garbage Disposal(Y/N) Y
D¡stance to Nearest Community SewerSystem:2500
Was an effort made to connect to the Community Sewer System: No
Potable Water Source
& Type
ü Well E Spring fl Stream or Creek û cistern
E Community Water System Name
Garfield County Public Health Department - working to promote health and prevent disease
Applicant acknowledges that the completeness of the application is conditional upon such further
mandatory and additional tests and reports as may be required by the local health department to be
made and furnished by the applicant or by the local health department for purpose of the evaluation of
the application; and the issuance of the permit is subject to such terms and conditions as deemed
necessary to insure compliance with rules and regulations made, information and reports submitted
herewith and required to be submitted by the applicant are or will be represented to be true and
correct to the best of my knowledge and belief and are designed to be relied on by the local
department of heahh in evaluating the same for purposes of issuing the permit applied for herein. l
further understand that any falsification or misrepresentation may result in the denial of the
application or revocation of any permit granted based upon said application and legal action for perjury
as provided by law.
I hereby acknowledge that I have read and understand the Notice and Certification above as
well as have provided the required information which is correct and eccurate to the best of
my knowledge.
Crook Bernard Crook
701t312022
Owner Print and Sign Date
Page 5 of3
lipdated Dec 2{11"}
Special Conditlons:
Perm¡t Fee:+p?.@ Fees:ooTotalgryz oo
t6ryzFees Paid:
Building Permit
?-urF-æg3l
OWTS Permit:spr-?8451 lssue Date:t"'"ä7', "'
Garfield County Public Health Department:
Slgned Approval
TÐB(|
Date
11/15/2022