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HomeMy WebLinkAboutApplicationDocuSign Envelope lD: DFFA28D5-EFB3-4CBD-94C8-8C957CF08FOE 3*f ä, 1:21" l:l:t:*r ?,iTl*, t{} *i{:!:i: l*?*t t2.t-t7{i* TYPE OF SYST€M CONSTRUCTIÛN ff Ne* l*¡taliatian BU¡LDING USAGE TYPË Ø. *we1li*g .* lran*i*rzzllsc * úther üeser?i:e i.ir:üHIVE[! i::" . ii jhiTY l¿U/u¡¡!iu,ì¡ i, i.,¡: ; ;::,..(JplvlEllT.Gxr.fielå Cr*urcg; á,zE!*f â¿: 8l*ælzlr TWTE PERMIT ÅPPLICÂTIÛNI 7*tr.4 *l*?.t i+'¿**¡;t ú1* r',v¿ * *4 2 pr irzç, {{, & l1t} 2. 197*'Í *43-{t{;a'24 i * AtLertti*T1 ü d*mr*.flrtdustrini i * ílepair ' * ?'¿{}{1-"**{*{-trlat- lNvor.v€D Propeny Mailing Address !m¡il Address: conúi"to,,. {ylyyli¿rt *(oylj*rv*ãM it ono, Mailing Àddress FmailAddre'ss: Mailing Address: Email Address; PROJECT LOCATION AND Job Address: Assessor's Parcel Building or Se¡uice Dístãnce to Nparest Ëommun¡ty Sewer Systeñ:t/, h^il¿g lÂlas a¡ effort m¿dë tð çañnect tç thè Commiln¡tï set¡rer 5y5tÉn1, - N,0 Potable Water Source & Type Well * Sprine ú llre¡ø¡¡{:eek -ü ticter* * (ommunlty Wa1Êr Syst€m #arí;eld **zs*lv ?t:=':i: 14*ø11* *ep**zt<z*t*,zs*rkir:ç t* *T*r*öl& **ai1?,2. a;24 ,ret?ra *1?*atz DocuSign Envelope lD: DFFA28Ds-EFB3-4C8D-94C8-8C957CF08FOE CERTIFTCATIOT¡ I hereby acknowledge that I have reãd and understaîd lhe Notice and çerlificãtion above as well as have provided the required information which is eor€ct ¿nd accurate to the best of my knowledge. Aûnlìcaìt ¿rkno'.vleeJÊos tlr;ll the romplrìc nr:r ,rt llrr' applir ¡lioil ¡\ r nn(iit¡onJi uporì sur h f urll¡e r man*ator¡.- ¡nd aclditîonal rIil( ¿rìd !pliortq,t", ¡n¡,,ir| reril¡r'rrl tr,'t|ì4 lnr.Jìhc.¡llh tleË¡rtmenl to lr¡ nracie¡ndfurrlisircdLlytl'n.r¡rnlicanìor llylirr, lor¡l heallhrir,,.ràrln¡r.nl fÕrp!rrpfiseof lhd Fvaludt¡o¡ìÕi the åppli.àtlorl;,lnrf tlin ¡tli¡¡'irn,'rlllro permrt ¡5 ruhlerÌ t(ì iu, l, lr'r'-r.ì,.rrd icn(ltltÕn\ ¡s di-,emeri rìê( p55åry 1o ¡n',r¡rê {órrtpi an, p rrlth rr¡les and rr'¡rrlalrnn', m¡d, , ':lform¿tr{rn ;ltl} te¡lrt, c,;bnl¡?lcrl he rervit h a nd re ctu ire cl te, bÊ r$þ*1i!!ed by t he 4ût3ti(.ôt1t ;trt sr vitll be re7:rt""e*let) 1ç 'tte tf .te "3*tt correcr to the beit Çf nry knt!{'le.t ge a*d Il*lit* afidare t1t::,tgn+t) lrs br: relu:rj {}111}\ì t*e lçtat df,parlment oi ht'alth irr evalualr;rI thc çanre for prtrposel or rq,,u rìq th{] l)f'rm;1 ¿nplrr:'d for herern. I f unher u¡rClerSt¡neJ th¿t dnV f¿llrliiailon Or rniSleprf'5CRt,ìlton m.lV r¡',t:ll tn lhp tl' ¡ri¡l r:l thC agplicatían or rev¡::catiÕn üf any permit grântúd bas*d uç*n taitl a{tþtir:atr*n aní1e8ãl aeti*n l.}{ ûe{iúr\t as provided Ìry l.rw. i I ¡ I* g ftg * æ ?, : ¿ ê, z a â Ë r ETf x r I e I â Ë â* Ë Ë I 7* ç nt : ; /-DocuS¡gned by:l,/á€øz 1_1./29/2022 --ir"æFfryîA{H.Print an o si g n Datê r4 OFFICIAL USE ONIY oc) Speciãl cond¡tions:,( q5Totål FeËsr#-¡'74"'""ï"h?.ot'1#ffi9" Buildinq Permitar?tr-ìlqllQ 0WTS Permit:.\ErlF-lqu3 lssue Dätê:"'ä2ç"bo Gãrfield County Public Health Department: 5¡gnÊd Approvã¡Dâte . .- .t.l.. .,.::,1 01/17/2023 01/18/2023