HomeMy WebLinkAboutApplication-PendingGurfteld Coun$
195 w. 14th street
Rifle, CO 81550
(e7o) 62s-s200
Public Heulth
OWTS PERM IT APPLICATION
2014 Blake Avenue
Glenwood Springs, CO 81601
(970) 94s-6614
WPE OF SYSTEM CONSTRUCTION
New lnstallatio Major Repair i
tr Minoiiedir-_-i tr Alteration EI Vault and Haul
BUITDING USAGETYPE
Dwelling E Transient Use E Comm./lndustrial tr Non-Domestic
) 97G309-3209
MailingAddress 540 Panoramic co 8'1650
Email Address:stv.wells@qmail.com
Contractor: Owner Phone:
Mailing Address:
i Email Address:
E Other Describe
Anderson Huddleston ) 970-255-8005
Mailing Address:2789 Riverside Pkwv , Grand Junction, CO 81501
EmailAddress:@m
PROJECT TOCATION AND DESCruPNON
JobAddress: 540 co 81650
Assessorr's Parcel Number: 212736400013
-Sub.
Panoramic Mesa bt_]!_Olock
Building or Service ADU 2 Disposal(Y/Nl_Y__
Distance to Nearest Community Sewer System:unknown
Was an effort made to connect to the Communlty Sewer System:no
Potable Water Source
&Type E Community Water System Name
E well E Spring E Stream or Oeek Xcstern
Garfield County Public Health Department - working to promote health and prevent disease
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I
CERTIFICATION
I hereby acknowledge that I have read and understand the Notice and Certlflcatlon above as
well as have provided the required information which ls correct and accurate to the best of
my knowledge.
Owner Print and Date
Applicant acknowledges that the completeness of the a pplication is conditional upon such further
nijnajtorv and addid'ronal tests and rdports as rnay be required by the local health department to be
;;d;3nd'f;rnistreU Ov the applicant oi by ttre lociil health departinent for purpose oithe evaluation of
the application; and tlie issuiice of the permit is su.bject to such terms and conditions as deemed
neceisary to iniure compliance.with rulds and regu.lations made, information and.reports submitted
herewith'and reguired t6 be submitted by the _applicant are or will be rep.resented to be true and
correct to the be;t 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
fuither understand that any falsifiEation 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.
OFFICIAT USE
Speclal Conditions:
THib,o.,Total Fees:
( d){J Po Fees Paid;p(,ffi
#\Ytr'frhsrt
OWTS Permit:bifi4ste-:lssue Date:Balance Due:r'A-'
Garfield County Public Health Department:
Signed Approval Date
Garfield County Public Health Department - working to promote health and prevent disease