HomeMy WebLinkAboutApplication - PENDING195 W. 14th Street 2014 Blake Avenue
Rifle, CO 81650 AZ
���,��� CountyGlenwood Springs, CO
(970) 625-5200 81601
Public Health (970) 945-6614
OWTS PERMIT APPLICATION
TYPE OF SYSTEM CONSTRUCTION
❑ New Installation Vmajor Repair ❑ Minor Repair I ❑ Alteration ❑ Vault and Haul
BUILDING USAGE TYPE
Dwelling ❑ Transient Use
❑ Other Describe
INVOLVED PARTIES
❑ Comm./Industrial ❑ Non -Domestic
Property Owner: 1A
I� 1t Phone: (Wo ) /v3 7 —19611
Mailing Address:
Email Address: k
Contractor: s� SsnP, a Phone
PL) : 7b)
Mailing Address: C7 Z S 1, C 0
Email Address: f USSeI tAA-S Z, ci4aA
Engineer: (4da_ 05eatrq_Phone: 7.0) 30-S"Z.57'
Mailing Address: 0/ t eo Prr uC 137 Bair (e Z3
Email Address: ORA%ow, (...
PROJECT LOCATION AND DESCRIPTION �% l�
Project Address: S M - �X.� 00 Te7
Assessor's Parcel Number: Q 13ZR I Sub. l" q- , Mrwor Lot7a-f Block
Building or Service Type: Ha me- #Bedrooms: 3 Garbage Disposal(Y/N)-&/
Distance to Nearest Community Sewer System: ar I�e.
Was an effort made to connect to the Community Sewer System: N 0
Potable Water
Source & Type
1K Well ❑ Spring ❑ Stream or
Creek
❑ Community Water System Name _
❑ Cistern
Garfield County Public Health Department — working to promote health and prevent disease
CERTIFICATION
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
erms and conditions as deemed necessary to insure compliance with rules and regulations
3ade, 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 information which is correct and accurate to the best of
m knowledge.
If Im VD,)-8e1-5
Property Owner Print and Sign
Date
C�
OFFICIAL USE ONLYTO:
-
WO
Special Conditions:
Permit Fee: � QD
Total FeesA, cc
Fees Paid: ` r, QO
Building Permit
OW ermit:
Issue Date:
Balance Due: 00
r
Garfield County Public Health Department:
Signed Approval
Date
Garfield County Public Health Department - working to promote health and prevent disease