HomeMy WebLinkAboutApplication-PendingGurfield Coanty
Public Health
195 w. L4th Street
Rifle, CO 81650
(e70) 52s-s200
20L4 Blake Avenue
Glenwood Springs, CO 81601
(970) 94s-6614
OWTS PERMIT APPLICATION
TYPE OF SYSTEM CONSTRUCTION
I ruew lnstallation E Major Repair E Minor Repair E Alteration E Vault and Haul
BUILDING USAGE TYPE
tr Dwelling E Transient Use a Comm./lndustrial tr Non-Domestic
E Other Describe
INVOTVED PARTIES
Property Owner: Phone zI 970 | 62
MailingAddress: 320 Main St.. Meeker. CO 81641
Email Address:kalierEmsoreadvmix com
Mix ( 970 t7 1
Mailing Address:PO Box 1550
Email Address:clanrOmsoreadvmix.com
Engineer: Pho ne:( 970 | 250-0572
Mailing Address:1131 24 Road. Grand Junction. CO B 1505
Email Address:kach avla. cro n k(O outloo k. co m
PROJECT TOCATION AND DESCRIPTION
Job Address:110 Gas Ct.. Rifle. CO 81650
Assessor's Parcel N 217718201005 W. Rifle lndustrial Park 5
Building or Service Type: Restroom for Business #Bedrooms:0 Disposal(Y/N)_N_
Distance to Nearest Community Seurer System:Aooroximatelv 1/2 Mile
Was an effort made to connect to the Community Sewer System:Yes
Potable Water Source
& Type
tr well E Spring tl Stream or Creek E Cistern
O Community water System Name Citv of Rifle
Garfield County Public Health Department - working to promote health and prevent disease
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'lrr i lf,i[,,,i': ;;,)y)
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
4t8t2024
Owner Print and Sign Date
)
Special Conditions:
co)Fees Paid:(oooPermit Fee:krrtP Total Fees:locnP
Building Permit OWTS Permit:
5EPT-8tra
lssue Date:Balance Due:+
Garfield County Public Health Department:
Signed Approval Date
Garfield County Public Health Department - working to promote health and prevent disease