HomeMy WebLinkAboutApplication-Pending195 W.14`h Street
Rifle, CO 81650arfield County
(970) 625-5200 Ee
Public Health
OWTS PERMIT APPLICATION
TYPE OF SYSTEM CONSTRUCTION
❑ New Installation CR Major Repair
BUILDING USAGE TYPE
Dwelling TO Transient Use
❑ Other Describe +- A 0U
INVOLVED PARTIES
2014 Blake Avenue
Glenwood Springs, CO
81601
(970) 945-6614
❑ Minor Repair ❑ Alteration ❑ Vault and Haul
❑ Comm./Industrial ❑ Non -Domestic
Property Owner: 0Vc en C4Y"4y'1 Ic, krjc 1 cil. I `e )-Phone: 15
Mailing Address: q3X Cli,,w. .) c i i.rM4ham, AI
Email Address: Kj,�bn :4 ma� t ci!nn
Contractor: ()-, ►.�r�i Ci qua �-� C _ Phone: (ct7o ) �171- 0cli3
Mailing Address: ii-�530 n, �� rc Gil rGc je C-0 !&U i
Email Address: A ia EL 0_lxmtx� I % o
Engineer: -7—i n _ova,- L J _ _ Prone: (q70) 30 - Q0;-
Mailing Address:
Email Address: Cq1Lr L K ,2� MCI 1 1, 6,0
PROJECT LOCATION AND DESCRIPTION
Project Address: 1 1 -
Assessor's Parcel Number: vo t ub. Lot Block
Building or Service Type: cx #Bedrooms: -I —Garbage Disposal(Y/N)_
Distance to Nearest Community Sewer System: '
Was an effort made to connect to the Community Sewer System: TA
Potable Water CA Well ❑ Spring ❑ Stream or ❑ Cistern
Source & Type Creek
❑ Community Water System Name Cetv
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
urther 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
arms 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
for 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.
L-
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. CM �c, tip
I c,►mn ko; L boa I
Property Owner Print and Sign
Date
OFFICIAL USE ONLY2,L
Special Conditions:
Permit Fee: ux, 0c)
Total Fees: If G0
Fees Paid:
Building Permit
OWTS Per . +
'Yssue Date:
Balance Due:
Garfield County Public Health Department:
Signed Approval Date
Garfield County Puhlir, Health Denartment — workino to nromote health and prevent disease