HomeMy WebLinkAboutApplication-Pending195 W. 141h Street 2014 Blake Avenue
Rifle, CO 81650 (970)625-5200 Garfield Qld County Glenwood Springs, CO
EC -
81601
Public Health (970) 945-6614
DINTS PERMIT APPLICATION
TYPE OF SYSTEM CONSTRUCTION
I
New Installation ❑ Major Repair ❑ Minor Repair ❑ Alteration ❑ Vault and Haul
BUILDING USAGE TYPE —'
❑ Dwelling ❑ Transient Use ❑ Comm./Industrial I ❑ Non -Domestic
XOther Describe 1"A GA(cL7uR-At. }6,_S-F kg z.
INVOLVED PARTIES
Property Owner: -- ptI -Li: 4.. ,Phone: (a�'� ) -i.3_ - �1_39y
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Mailing Address: 5718 `Rayo-i citzF_,t nz- ;4 ,�,.�a�,� �,��,r"cc S(Go1
Email Address:
Contractor:
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_ Phone: `1�9
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Mailing Address:
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Email Address:
Engineer: �,���
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Mailing Address: -11C� sit A,c:. Sc _ci ���,.�..�c� S►���,J�s� Cc 6cot
Email Address:-��.�h�
PROJECT LOCATION AND DESCRIPTION
Project Address: "+ r � r�.�E Sr Rt;.,�s ^;y,���-4 , ;iE,�i
Assessor's Parcel Number: Sub. QNTioE Lot D Block k
Building or Service Type: Ag, #Bedrooms: Q Garbage Disposal(Y/N) 0
Distance to Nearest Community Sewer System: N 1P•
Was an effort made to connect to the Community Sewer System: _ t1) r�
Potable Water 9 Well ❑ Spring I ❑ c+roa;;; I ❑ "'Stern
Source & Type Creek
L ❑ Community Water System Name
Garfield County Public Health Department — working to promote health and prevent disease
,pplicant acknowledges that the completeness of the application is conditional upon such
irther mandatory and additional tests and reports as may be required by the local health
epartment to be made and furnished by the applicant or by the local health department for
urpose of the evaluation of the application; and the issuance of the permit is subject to such
arms and conditions as deemed necessary to insure compliance with rules and regulations
lade, information and reports submitted herewith and required to be submitted by the
pplicant are or will be represented to be true and correct to the best of my knowledge and
elief and are designed to be relied on by the local department of health in evaluating the same
)r purposes of issuing the permit applied for herein. I further understand that any falsification
r misrepresentation may result in the denial of the application or revocation of any permit
ranted 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 informa ' is correct and accurate to the best of
my knowledge.
covo "t, f a 10 I Z 1) Z IS,
Property Owner Print and Sign
Date
OFFICIAL USE ONLY
Special Conditions:
Permit Fee: ClO
Total Fees:
Fees Paid Od
Building Permit
OWTS Permit:
Issue Date:
Balance Due: �—
Garfield County Public Health Department:
Signed Approval Date
Garfield County Public Health Department — working to promote health and prevent disease