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HomeMy WebLinkAboutApplication195 W. 14`" Street Rifle, CO 81650 (970) 625-5200 Garfield County Public Health Health 2014 Blake Avenue Glenwood Springs, CO 81601 (970) 945-6614 OWTS PERMIT APPLICATION TYPE OF SYSTEM CONSTRUCTION igc-New Installation 1 ❑ Alteration BUILDING USAGE TYPE 0 Dwelling In Transient Use i ❑ Comm./Industrial ❑ Other Describe ()Cr'i4 GHC 6 -6 ` Oc.k Le' ❑ Repair © Non -Domestic • - _� a INVOLVED PARTIES Property Owner: )j pan Led of c (44. C4AL cr, 1- C Phone: (L77.2 )- 2 e 3 (1 `i S `t'N11a CCUfl ice. 2011 COIo ,, ' P la 30 Mailing Address: Email Address: 1 4'C-e 2 L w'aA)e�'� r Oc.lG. re, p 1 Contractor: 5 iL V� IiF(F-iZ ' i�r#ILCe'd- Phone: ( �r'?� j 2 1 i 1 Mailing Address: 761. 12.E , Fria RI J 2( Email Address: Engineer:-iur d le star - 114111 Phone: ( 9'7U ) 2E - f c;0$ Meiling Address: Email Address: '2? $`i l viff l kw�e 6tat1 Ju4cfieml 'i, ''j tocio £ 14Lutdte s fc,.i b f(it . tom PROJECT LOCATION AND DESCRIPTION Job Address: Assessor's Parcel Number: 2) 73 3 cx O 2 3 Sub. Lot — Block — Building - Building or Service Type: Dr1c cke, [a ra J c" #Bedrooms: +✓i Garbage Disposal(Y/N)_ CD Distance to Nearest Community Sewer System: +" 3 D i'►'1 i )e. Was an effort made to connect to the Community Sewer System: 1\0 - NU i Po Ss ir3Ce- Potable Water Source BLwell 0 spring ❑ Stream or Creek 0 Cistern & Type ' ❑ Community water System Name Garfield County Public Health Department - working to promote health and prevent disease -77 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 conl!plidru a 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 heallii in evaluating the same for purposes oh issuing the permit applied for herein. I 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. Property Own r Prin and Sign Date OFFICIAL USE ONLY Special Conditions: v. �. Permit Fee: I25.00 Total Fees: Fees Paid: 123. OD eulidin Permit 13Lk-bVti OWTS Permit; S r-ioi5z Issue Da 4 ZG � oL T 7 Balance Due: fG1 Garfield County Public Health Department_ = ;Qc j/ 67�%�UZe, Signed Approval' Date .13-op, CL) 3I(4Z IOW