HomeMy WebLinkAboutApplication195 W. 14th Street
Rifle, CO 8L650
(970) 62s-s200
Public Heulth
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201"4 Blake Avenue
Glenwood Springs, CO 81601
(970) 94s-6614
OWTS PERMIT APPLICATION
Garfield County
TYPE OF SYSTEM CONSTRUCTION
Z New lnstallation I Major Repair E Minor Repair E Aheration E Vault and Haul
BUILDING USAGE TYPE
A Dwelling tl Transient Use tr Comm./lndustrial tr Non-Domestic
I Other Describe
INVOTVEDPARTIES
Email Address:siz26@comcast.net
Property Stephen & Jennifer Zaneticfl {856 14721831
Mailing 8 Oakview Terrace, Swedesboro NJ 08085
I
(tTo Be Determined
Mailing Address:
Email Address:
Email Address:cada.ostbelg@qmaiLcgtr
Mailing Address:W
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PROJECT TOCATION AND DESCRIPTION
ASSeSSOTTS ParCel NUmber.218528200033 Sub. None L6tParcelA BIOCk
Was an effort made to connect to the Community Sewer System:
JOb AddreSS: tbd Mountain Springs Ranch Road
No
Distance to Nearest Community Sewer System > 5 miles
Disposal(Y/NBuilding or Service Single Family Residence
E Stream or Creek E CisternEl Well [J SpringPotable water Source
&Type E Community Water System Name
Garfield County Public Health Department - working to promote health and prevent disease
i 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 acknowledgethat 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
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Property Owner Print andSign Date
OFFICIAL USE ONLY \
Special C.ondhlons:
Permlt fee:
.oo Total Fees:a oo
Permh OWIS Permit:,qq lssue Dat€:Balance Due:
Garfield County Publlc Health Department:
Signed Approval Drte