HomeMy WebLinkAboutApplicationRECEIVED
GARFIELD COUNTY
COMMUNITY DFVELOPh EST
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 ❑ Alteration I ❑ Repair
BUILDING USAGE TYPE
Dwelling ❑ Transient Use I ❑ Comm./Industrial ❑ Non -Domestic
0 Other Describe
INVOLVED PARTIES
Property Owner: GEORGE H DANIELS, ill
Mailing Address: 176 GH DANIELS BLVD, GYPSUM, CO 81637
Email Address: ghdyrowit@ao!cam
Phone: ( 970 ) 471-0920
Contractor: GEORGE H DANIELS.111
Mailing Address: 176 GH DANIEE SBLVD. GYPSUM, CO81637
Email Address: ghdgrowit@Hatcam
Phone: ( 970 ) 471-0920
Engineer: JEFF SIMONSON
Mailing Address: 118 W. SIXTH ST., SUITE 200 GLENWOOD SPRINGS, CO 81601
Email Address: JEFF@SGM-INC.COM
Phone: (
PROJECT LOCATION AND DESCRIPTION
Job Address: TBD QUICKSILVER CT., RIFLE, CO 81650
Assessors Parcel Number: 217722301007 Sub. QUICKSILVER COURT
Lot 7 Block
Building or Service Type: DWELLING #Bedrooms: 4 Garbage Disposal(Y/N) Y
Distance to Nearest Community Sewer System: 20 MILES
Was an effort made to connect to the Community Sewer System: TOO FAR
Potable Water Source
& Type
IR Well Q Spring
❑ Stream or Creek
0 Cistern
❑ 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 per mit 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
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 informat'rg j which is correct and accurate to the best of my knowledge.
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Property ner Print and Sign
Date
OFFICIAL USE ONLY
Special Condition::
Permit Fee:
Total Fees:
-Fees
i
Paid:
Building Permit
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OWTS Permit:
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Issue Date:
G7`��os��•,z,:
Balance Due:
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Garfield County Public Health
Department: </.� Gti`"T
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0 Vf>lee
Signed Approval
Date
13,3 o:3) 101-) 3 1'2-12U7,0