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195 W. 14th Street
Rifle, CO 81650
(9701 62s-s200
Publíc Heølth
OWTS PERM IT APPLICATION
2014 Blake Avenue
Glenwood Sprlngs, CO 81601
(970) 94s-6614
WPE OF SYSTEM CONSTRUCTION
New lnstallation E Alteration tr_Repair
BUILDING USAGETYPE
iÉ Transient Use lndustrial tl Non-Domestic
r¡rvowEDl4!flis_
Prcperty Owng¡¡ CMH Homes lnc Phone¡ f 970 ) 245-9039
Mailing 671 23 Road Grand Junction, CO 81505
Emall Address:staci.douglas@claytonhomes.com /
Homes ( e7o ) 245-so3e
MalllnßAddress;671 23 Road Grand Junction, CO 81505
Email Address:staci.douolas(ôclavtonhomes.com /
I ozn-t¿.L-zaze
MaillngAddress:2516 Foresiqht Cr #1 Grand Junction. COBI505
I
E Dwelling
El other Describe
EmallAddress:
PRO¡ECT TOOATION AND DETCRIPTIOI{
lob Addrcs¡: TBD County Rd 237 Silt, CO 81625
Assesso/s Parcel 2127 241 01 002 l¡t_Block_
Bulldlng or Servlce HUD Code Home 3 Garbage Dlsposal(Y/Nl No
Dlstance to Neerest Communlty SewerSystem:400'olus
lryas en effort made to connect to tfie C.ommunlty Seurcr System, No
Potable WaterSource tr Well tr sprlng E $rcam or Creek E d¡tsm
&Type D Communlty Water Sy$cm Neme
-
Gørfield County
Garfield County Public Health Department - working to promote healih and prevent disease
Applicant acknowledges that the completeness of the application isconditional upon such further
niindatory and additional tests and réports as may be required by the local health department to be
made andÎurnished by the applicant ol by the local health department for purpose of the evaluation of
the applícation; and tlie issuáñce of the permit is subject to such terms and conditions as deemed
neceisãrv to inlure compliance with rules and regulations made, information and reports submitted
herewith'and required tó be submitted by the applicant are or wlll be represented to be true and
correct to the bebt of mv 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 perm¡t applied for herein. I
further understand that any falsification or misre-pre-sentat¡on may result in the denial of the
application or revocation oi any permlt granted based upon said applícation and legal action for perjury
as provided by law.
CERTIFICATION
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 knowledge.
10t2712023
Property Dete
Page 5 of3
Updated Dec 201!
Sign
OFFICIAL USE ONIY
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Spcclal Gondhlons:
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Bulldlns Pêrmh
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OWIS Permlt:
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ls6ue Dðtc:B¡hncc Due:
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Garfleld County Public Heahh Dcprrtmcnt:
SEncd Approval Date
11/22/2023