HomeMy WebLinkAboutApplication - PendingI
195 W. l-4th Street
Rifle, CO 81650
(e70) 62s-s200
Public Heulth
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2014 Blake Avenue
Glenwood Springs, CO 81601
(s70)e4s-66r4
OWTS PERM IT APPLICATION
Gurfield County
TYPE OF SYSTEM CONSTRUCTION
E New lnstallation E Major Repair E Minor Repair E Alteration fl vault and Haul
BUILDING USAGE TYPE
A Dwelling E Transient Use tr Comm./lndustrial tr Non-Domestic
E Other Describe
INVOLVED PARNES
Property ()
970 925.2855
Mailing Address
Email Address:
Contradon Beek Ruilding Gompany; Steve Boders{tone:( | 929,471,1684
Mailing aaar"tr780 Nottingham Road
Emait Addresr. steve@beckbuilds.com
Engineer:c\^^-:^ E^^:^^^-i^^, t-)^,,t D,.+t^l^^Phone:
wr qurr\qrrsvvg
MailingAddresS02 Main Street, Suite A-3; Carbondale, CO 81623
Email Addres.. prutledge@sopris.com
Job Address:
Assessor's Parcel N
Building or Service
000042 srld.eathcote West Tractqot G-8 elock
Single-Family Bedrooms:3 Ga rbage Disposal(Y/N) Y
Distance to Nearest Community Sewer System approx.10 miles
no
Was an effort made to connect to the Community Sewer System:
Potable Water Source
& Type
E Well tr Spring E Stream orCreek E Cistern
f; Community Water System Name vvYssLYvqLsr r \qr rur r \}Jt tYqtg,,
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
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 subjectto 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 anyfalsification 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 $/^-Y ?u*6126125
Property Owner Print and Sign Date
sOFFICIAL IJSE ONLY a+
Special Conditions:I
Fees Paid:
t#( o nh -60
Permit Fee:
d lBoA,*
Total Fees:
${10CI. co
OWTS Permit:
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lssue Date:Balance Due:$fi"aaBuilding Permit
Garfield County Public Health Department:
Signed Approval
f
Date
Garfield County Public Health Department * working to promote health and prevent disease