HomeMy WebLinkAboutApplication-PendingGarfield Coun$
Public Health
195 W. 14th Street
Rifle, CO 81550
(970) 62s-s200
2014 Blake Avenue
Glenwood Springs, CO 81601-
(e70)e4s-66r4
OWTS PERM IT APPLICATION
TYPE OF SYSTEM CONSTRUCTION
E New lnstallation fl Major Repair E Minor Repair tl Alteration E Vault and Haul
BUITDING USAGE WPE
IS Dwelling ! Transient Use n Comm./lndustrial tr Non-Domestic
flOther Describe
INVOTVED PARTIES
Property a'l I
970 925.2855
Mailing Address:
Email Address:
+O+U V.ill l\955 \)l,lCe[ l\VV, VVcl$lllllgLull lJ.\z. ZVV lZ
contractor: neek nuilding esmpany; Steve nederiRnone:( | 979,421,1654
Mailing AddressTS0 Nottinoham Road; Avon, CO 81620
Emait Addresr. steve@beckbuilds.com
Encinee* sopris Engineering; Paul Rutledge Phone:
MailingAddres$02 Main Street, Suite A-3; Carbondale, CO 81623
Emait Address. prutledge@sopris.com
PROJECT I
JObAddfeSS: tfLuu owEcLwcltEl ndllutl nu€lu 4( I# |YIO>.5-'?LX)lA I
Assessorr's Parcel Numbe 3000042 sJd.eathcote West Tractqot G-7 slock
Building or Service Single-Family Bedrooms:2 YGarbage Disposal(Y/N)_
Distance to Nearest Community Sewer System:approx.10 miles
no
Was an effort made to connect to the CommunitySewer System:
Potable Water Source
& Type
El Well D Spring E Stream orCreek I E Cistern
ft CommunityWater System Namg "rr"-(rYqrvr r \sr rvr r \Hr rYqrv/,
Garfield County Public Health Department - working to promote health and prevent disease
CERTIFICATION
Applicant acknowledges that the completeness of the application is.conditional upon such further
"i"nOriory
and additi"onal tests and reports as may. be required by the local health de-partment to be
rrJ"ira't"rnirtr"O by the applicant or by the locdl health department for purpose of the evaluation of
tfre application; and tlie issuince of the pbrmit is su.bjectto such terms and conditions as deemed
n"ieirriV to iniure compliance with rules and regulaiions made,.information and.reports submitted
f,"i"*iif''rnd required til be submitted by the applicant are or will b.e rep.res.ented to be true and
forr".t to the beit of my knowledge and belief and are designed to be relied on by the.local
department of health in'evaluatin[ the same for purposes of issuing the permit applie.d for herein. I
tulttrer understand that any falsifiiation 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 understand the Notice and Certification above as
well as have provided the required information which is correct and accurate to the best of
my knowledge.
Lauren Mason $/^-V h,*6126125
Property Owner Print and Sign Date
OFFICIAL USE ONLY I
Special Conditions:
Fees Paid @a
Total Fees:b6.oc/'"Gibpc,
Balance Due:
*
lssue Date:Buildingw0 Permit
t2'q4?e
OWTS Permit:'6Etrt44a4-
Garfield County Public Health Department:
Signed Approyal Date
Garfield County Public Health Depa(ment * working to promote health and prevent disease