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C Ofui I,,Ji U I'{ ITY NEVE LOPMENT
195 W. t4th Street
Rifle, CO 81650
(e70) 52s-s20o
2014 Blake Avenue
Glenwood Springs, CO 81501
(s7ole4s-66L4
OWTS PERMIT APPLICATION
WPE OF SVSTEM COHSTRUCTION
lx New lnstallation EJ fUalor Repair
BUITDING USAGE WPE
lxl Drrelling E Transient Use
E Other Describe
E Minor Repair fl Alteration EI Vault and Haul
Comm./lndustrial fl Non-Domestic
Gurfteld County
IT{VOTVEDPARNES
Property0rngr; Puma Paw, LLC Attn: John Hilderbrant Plro,ns;( 97A 1 2224525
Mailing 1793 Gounty Road 219, Rifle, CO 81650
Email Address:jhilderblant42@gmail.com
CRB Construcfion, lnc { 970 1 618-7a93
Mailing Address:PO Box 1798, Carbondale, CO 81623
Emall Address:crbconsbuction@comcast.net
Kumar and Associales, lnc 1 s70 ) 94$.7e88
Mailing Address:5020 cR 1Ar, GWS, CO, 81601
Email Address:kaglenwood@kumarusa.com
PROJECT TOCATION AND DESCRIPnON
Job Address:CR 81650
Assessot's lJ,f]s;}4l1€sg6
Building or Service SFR Disposal(Y/Nl--l-
Distance to Nearcst Community Sewer System:7 miles
Was an effort made to connect to t{re Community Sewer Syst€m: No-
3
Potable WaterSource
&Type
xl Well Il Sprine E StreamorC.rcek E Clstem
E CommunitywaterSystem Name
_1,
CERNFrcAflON
Propefi Owner Printand Slgn
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 underctand the Notice and Certification above as
well as have provided the required information which is correct and accurate to the best of
myknowledge,
atlr;lzaztl
I
Date
OFFICIAT USE ONLY
Speclal Condhions:
Permit Fee:epGCN
Total Fees:
Qpoo oo t""dbo.*
Building Permit
Rt Otr -RG.r1
OWTSPemit:(\ET,T-RS-r\lssue Datc:Balance Due:-e-
Garfield County Public Health Department:
SignedApproval Date
2/13/2024