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19s w. 14th street
Rifle, CO 81650
(970) 62s-s2oo
Public Heølth
OWTS PERMIT APPLICATION
2014 Blake Avenue
Glenwood Springs, CO 81601
(970) 94s-6614
WPE OF SVSTEM CONSTRUCTION
tr lUew Installat¡on i E Alteration Repair
BUILDING USAGETYPE
E Dwelling EI Transient Use I n Comm./lndustrial I g Non-Domestic
ì
tl Other Describe
INVOIVED PARTIES
PropertyOwner: Sanchez, Guadalupe Phone:f 970 I 618-3087
Meiling 1519 Graystone Dr Carbondale, CO 81623
EmallAddress:staci.douglas@claytonhomes.com /
Contractors Sanchz,Guadalupe Phone¡( 9zo ) ole-soaz
MalllngAddress:Same as above
Email Addre¡s:staci.douqlas@clavtonhomes.com /
Westwater ( 970 1241-7076
MalllngAddress:2516 Foresight Cr #l Grand Junction, CO 81505
EmallAddress:
PRo,ECT LOCATION AND DETCRIPNOil
lob Addrcss:TBD Arrowhead Trail Rifle. CO 81650
Assessot's Parcel ilu 2403041 00047 Grass Mesa Ranch 52
Bulldlng or Servlce Type: Single Family Residence fBedrooms:_x__Garbage Dlsposal(Y/Nf N
Dlstance to Nearest C¡mmunlty SewerSystem:Over 400'
Was an ¡ffort made to connect to t{te C,ommunlty Sewcr System:No
Potable water source
& Type
Well tr Sprlng E StrcamorCreck tr osrem
El Communlty Water Systcm N¡me
Gørfield County
Garfield County Public Health Department * working to promote health and prevent disease
Applicant acknowledges that the completeness of the application isconditional upon such further
niai¿atorv and additional tests and réports as may be required by the local health department to be
mãAè àn¿'turnished by the applicant or by the locál health department for.purpo.se of the evaluation of
thè applicat¡on; and tlie issuáñce of the pärmit is subject to such terms and conditions as deemed
neceósãrv to iniure compllance with rulés and re8ulations made, information and reports submitted
Íiãiewiitr'an¿ iéquired tó be submitted by the apþllcant are or wlll be represented to be true and
àorrect to the beit of mv knowledge and belief and are designed to be relied on by the local
deoártment of health in'evaluatinãthe same for purposes of issuing the permit applied for herein. I
tuñtrei unUerstand that any falsifiıation or misreþre-sentation may result in the denial of the
appiícation oirevocatlon of any permit granted b-ased upon sald application and legal action for periury
as provided by law.
CERTIF¡CATION
I hereby acknowledge that I have read and understand the Notlce and Certification above as
well as have provided the required information which is correct and accurate to the best of
my
zo2
Owner Print and Sign Date
ltOFF¡CIAI USE ONIY æ
Speclal Condltlons:
Tot¡l Fe¡s:4løm.Ø *iljæ.*'#ffi.""
^'låil'*l¡5ue Date:Bulldlng Permlt
Atîttr-Aûg
OWIIS Permlt:
srPf - gÐ^Lt
Garfleld Coufi Public HGâ¡th Dcpartmcnt¡
Skned Approv¡l
f
Date
Page 5 of3
Updated Doc 20lJ
10/04/2023