HomeMy WebLinkAboutApplicationGørfteld County
Public Heølth
i.gs w. 14th street
Rifle, CO 81650
(970) 62s-s200
201-4 Blake Avenue
Glenwood Springs, CO 8160L
(970) 94s-6614
OWTS PERM IT APPLICATION
TYPE OF SYSTEM CONSTRUCTION
tr New lnstallation n Alteration tr Repair
BU¡LD¡NG USAGE TYPE
E Dwelling E Transient Use tr Comm./lndustrial tr Non-Domestic
I Other Describe Temporary Vault and Haul for Temporary Emplovee Housi
INVOTVED PARTIES
Property Phon e:í 970 I 618-3668
Mailing 6275 County Road 315; S¡lt, CO 81652
Email Address:coueyranch@gmail.com
Contractor: Representative: laramie Energy, LLC Phone:( 970 ) 812-s310
Mailing Address:760 Horizon Drive Suite 101, Grand Junction, CO 81506
Email Address:wbankert@laramie-energy.com
Engi one:T ì
Mailing Address:
EmailAddress:
PROJECT TOCATION AND DESCRIPTION
Job Address:
2169-022-00-030 lockAssessol's Parcel N
Building or Service
Su
Temp Housing See Na N
Disposal(Y/N)
Distance to Nearest Community SewerSystem' 13 mapped miles
Was an effort made to connect to the Community Sewer System: No
Potable Water Source
& Type
tr Well tr Spring EI Stream or Creek E Cistern
lCommunity Water System Name Water Hauler - See Narrative
Garfield County Public Health Department - working to promote health and prevent disease
CERTIFICATION
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 health in evaluating the same for purposes of issuing the permit applied for herein. I
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 accurate to the best of
my knowledge.
1,nu- I i^L/ 05/24/23
Property Owner Print and Sign Date
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:_}S OO Total Fees:r5 qO Fees Paid:-15 oo
Building Pçrmit
NJ/A
OWTS Permit:
3¿Q{ -€\¿to lssue Date:Balance [\,¡e:+-
Garfield County Public Health Department:
Signed Approval Date
06/05/2023