HomeMy WebLinkAboutApplication-Pending195 W. 141h Street
Rifle, CO 81650
(97tg M-',M
RECEIVED
-�- Garfield Count
y
Pubtic Health
7U4'5WJm0xunue
Glenwood Springs, CO 81601
(9701 R48-6614
OWTS PERMIT APPLICATION
TYPE OF SYSTEM CONSTRUCTION
MAY 2 8 202E
1A11FIELD COUNTY
`nMMUNITY REVEIA)PME&T
El New Installation ; ❑ Major Repair L❑ Minor Repair ❑ Alteration [ ❑ Vault and Haul
U»T
1 ❑welling I ❑ Transient Use ❑ Comm./Industrial ❑ Non -Domestic
❑ Other Describe
INVOLVED PARTIES
PropertyOwner. Burnt Tree Rid e. LLC Phone: ( 810 ] 459-0502
Mailing Address:_ 41500 Mound Road, Sterling Heights, MI 48314
Email Address: smancini@ric-man.com
Contractor: Phone: 810 459-0502
Mailing Address: 41500 Mound Road, Sterling Hei hts, MI 48314
Email Address: smancini@ric-man.com
Engineer: Boundaries Unlimited Phone: ( 970 ] 945-5252
Mailing Address; 923 Cooper Ave., Suite 201, Glenwood Springs, CO 81601
E1± M AddressC � Iri�9.ia i
PROJECT LOCATION ANl'1 DESCRIPTION
lob Address: -
Assessoes Parcel Number: Sub Lot3 Block N/A
Building or Service Type: ❑wellint #Bedrooms., 3 GarbageDisposal(Y/N) N
Distance to Nearest Community Sewer System: 20 Miles
Was an effort made to connect to the Community Sewer System: No
Potable Water Source Well 4 ❑Spring ❑Stream or Creek ❑ Cistern
& Type �❑ Community water System Name
Gar ield County Public Health Department — working to promote health and prevent disease
CERTIFICATION
Appiicant 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 subject to 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
fmg# e( or"S. tg1@xo;hat f4lsificatimn ar.mis�r,.+esentation may result in the denial of .the
_ - ` a*09mtarnd I gal adfim;
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
kno�Ied�
f'rope ner Print and Sign Steven Mancini Date
l$i ili{IM11[l-�Ict rt. C-/-.. 15 -
Permit Fee: Total Fees: Fees Paid:
9d (12
�J
Buildin Permit OWTS Permit:_ _ Issue Date: Balance Due:
NALL
Garfield County Public Health Department:
Signed Approval Date
Garfield County Pudic Health department — working to promote health and prevent disease