HomeMy WebLinkAboutApplicationRE
EIV ED
GARF1ELO COUNTY
COMMUNITY DEVELOPMENT
195 W. 14th Street
Rifle, CO 81650
(970) 625-5200
Garfield County
Public Health
2014 Blake Avenue
Glenwood Springs, CO 81601
(970) 945-6614
OWTS PERMIT APPLICATION
TYPE OF SYSTEM CONSTRUCTION
New Installation nRepair
BUILDING USAGE TYPE
Dwelling fnTransient Use n Comm./Industrial n Non -Domestic
❑Other Describe
INVOLVED PARTIES
Property Ownerc0.9-A ltL ' M►L,I CPI JC til 4,/e Phone: (C/1p )6/6 ' i?C6
Mailing Address: x3I Co, RJ. 326, ,j %LT Cv . 5Il 64 Z
Email Address: -Sc 4leike joiatel.s. ,t/6T
Contractor: e>4.....4 Phone: ( )
Mailing Address:
Email Address:
Engineer: Phone: (
Mailing Address:
Email Address:
PROJECT LOCATION AND DESCRIPTION
Job Address: .Si! co. e 32 (' s3 /4...(2.
Assessor's Parcel Number: 21 7 q Sub. 35-2 Lot ey2 Block .43 )
Building or Service Type: n+datrx'L`i #Bedrooms: 3 Garbage Disposal(Ya
Distance to Nearest Community Sewer System: &* 1 ' 5
Was an effort made to connect to the Community Sewer System:
Potable Water Source
& Type
ell L 5pring 05tream or Creek nCistern
I =Community Water System Name
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 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.
further understand that any falsification 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:
,0/1 -AA C 5' /fii K6K 29
Property Owner Print and Sign
2,- id —Zed 20
Date
OFFICIAL USE ONLY
Special Conditions: $ y f ein 4c, 6� Gp'vt fewc.. ed A. 5 S hact/+r, Ci vt p [RHs
by C 603 wc• da-irot Febtact ey z... 7i 2az0
Permit Fee:
RZ*. oa
Total Fees:
Fees Paid: �� `3' Od
Building Permit
BUMF- ,124
OWTS Permit:
se- 4.15-2-
Issue Date:
01/467 aza
Balance Due:
Garfield County Public Health Department: I i . 02 .9 fro
1
Signed Approval Date
1
PD. s12.3.00, 5i1, 2- io zozo