HomeMy WebLinkAboutApplication195 W. 14th Street
Rifle, CO 81650
(970) 625-5200
Garfield County
Public Health
RECEIVED
GARFIELD COUNTY
COMMUNJTY DEVELOPMENT
2014 Blake Avenue
Glenwood Springs, CO 81601
(970) 945-6614
OWTS PERMIT APPLICATION
TYPE OF SYSTEM CONSTRUCTION
M New Instaiiation [ ❑ Alteration
BUILDING USAGE TYPE
Dwelling J ❑ Transient Use I ❑ Commllndustrial
D Other Describe
D Repair
❑ Non -Domestic
INVOLVED PARTIES
Property owner: /1,11' .3ro n C� � L&SS�C r Phone: (7770 ) ODi . /1 y ri-
MailingAddress: P() 8m,' lc 95 ,Sc l (?0 8-/615
Email Address: bre ndiph(' sicr (6) m i 1 Corn
Contractor: P)hnC,u'1p /'i()mpS Phone: (er) ) Qtto •07Qb
Mailing Address:
Email Address: gi b,P r4 p_o(] (e) Cyneli l 00
Engineer: Caps Ilhn P .rpt se l ve s i- Phone: (c/70) Of -10 .--))3.3i
Mailing Address: 6,/ w Par ? (. Dr -1 vL crar,cl JLLhC-h r (ic") ?)s-64/
Email Address:
PROJECT LOCATION AND DESCRIPTION
Job Address: Ca (a /17/,5/9 D ,P (F1j CO 6-%4260
Assessor's Parcel Number:Z /ZQZrk/O3 (..)o7 Sub.eL le- C Y .(-$T Lot f Block
Building or Service Type: ICo5,rlpn-f-tr ( #Bedrooms: Garbage Disposal(Y/N) }�
Distance to Nearest Community Sewer System:
Was an effort made to connect to the Community Sewer System: 00
Potable Water Source ❑ well ❑ Spring ❑ Stream or Creek ❑ Cistern
YID -----
& Type ! l, Community Water System Name , ti /p crate f S TG r(-5 (}A
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. 1
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.
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Property Owner Print and Sign
i-av
Date
OFFICIAL USE ONLY
Special Conditions: A?Prd,t� ` ! per- rev+SreI re r,,,-c•b y
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Permit Fee:
Total Fees:
Fees Paid:
Building Permit
c31 -12-C;- (0 (
OWTS Permit:
s epr- (013(0
issue Date:
_ 03/40/reze
Balance Due:
o
Garfield County Public Health
Department:
e Pi4".-0310/zez0
Signed Approval Date
FV. 07-' / C j 2-122P'V70
Page 5 af 3
Lpdated Dec 2)[3