HomeMy WebLinkAboutApplication195 W. 14'1' Street
Rifle, CO 81650
(970) 625-5200
Garfield County
Public Health
2014 Blake Avenue
Glenwood Springs, CO 81601
(970) 945-6614
OWTS PERMIT APPLICATION
TYYE'OF SYSTEM CONSTRUCTION
New Installation
BG USAGE TYPE
Dwelling El Transient Use
D Other Describe
❑ Alteration
❑ Comm./Industrial
D Repair
❑ Non -Domestic
INVOLVED PARTIES / A� I
Property Owner: %%1+G�{� I i /CAA ! r Veio r/ $Phone: (3 ) e' -4i7B e+
Malling Address: l Q / /3 t 5.7✓4. a) Mem / LSO yea /
EmailAddress:Tr\ r m(45 � 1'31A L I.G43017
Contractor: dSJ hVJ
Mailing Address:
Email Addres :
Engineer: i + h1,� i e 1nL . Phone: { ` 701 argS-"6I 7 G
Malting Addres 1 sn (1 [Ski �v ,,/ t�1I �L(�(idd s S
Email Address: ! 1� 4 r ( ` I Y G I
Phone:
GT4 F1
PROJECT LOCATION AND DESCR PT1ON
Job Address: P (/ ��-- Se,—)
q / Block
Building or Service Type: Avri C 5eif14L UBedroams: S Garbage DIsposa1(Y/N)
Assessor's Parcel Number:Z /4-91/0/o VSub. - I 75 Lot
Distance to Nearest Community Sewer System:
Was an effort made to connect tgthe Community Sewer System: NI D 0 " v
Potable Water Source dwell ❑ Spring i ❑ Stream or Creek
&Type 0 community Water 5ystemtame
0 Cistern
Garfield County Public Health Department — working to promote health and prevent disease
r
RECEIVED
GARFIELD COUNTY
COMMUNITY DEVELOPMENT
CERTIFICATION
Applicant acknowledges that the completeness or 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 areo de information
nd reports
e r submitted
herewith and required to be submitted by the applicantitrepresented osrue
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.l
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
1 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.
Prope
Print and Sign
OFFICIAL USE ONLY
spedal Conditions:
ate
Permit Fee: y
adPerrnk714
Total Fees: lI 2
iIr r
3D Permit: Issue Date:
pr- all 44/0Et 04:9
Garfield County Public Health Department'.
Fees Paid: /23
Balance Due: 1
C
Signed Approval date
PD. 1Z3•0(6 !.C? 41►3?.vta
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