HomeMy WebLinkAboutApplication195 W. 14th Street
Rifle, CO 81650
(970) 625-5200
Garfield County
2014 Blake Avenue
Glenwood Springs, CO 81601
(970) 945-6614
OWTS PERMIT APPLICATION
TYPE OF SYSTEM CONSTRUCTION
H New Installation
BUILDING USAGE TYPE
❑ Alteration
0 Repair
❑ Dwelling L❑ Transient Use j ❑ Comm./industrial
0 Other Describe
0 Non -Domestic
INVOLVED PARTIES
Property Owner: Locnhnbrnm ramify lmstGT) Lowell Waller Phone: ( 970 ) 949.3271
Mailing Address: 6530 c 331. s3. CO 61652
Email Address: Lowell Waller Klwauereiearnpsm.cam,
Contractor:Fleyl Construction Phone: (97p
) 804 3404
Mailing Address: 6560 CR 335 New Castle. CO 81647
Email Address: nave liayl,dhayleheylciyil.cam>
Engineer: Sopris Engineering, haul Rutledge and Yancy Nichol Phone: (
)
Mailing Address: 502 Main Biwa SuiloA3,Carbondale.CO01023
Email Address: prulledgar{Ji sopnseng coot
PROJECT LOCATION AND DESCRIPTION
Job Address: 6538 CR 331, Sr11, CO 81652
Assessor's Parcel Number:
Building or Service Type:
Distance to Nearest Community
Was an effort made to connect
2401 1 120°206 Sub.
Lot Block
Residence #Bedrooms: 5
Garbage Disposal(Y/N) N
Sewer System: ' Rinne
to the Community Sewer Systern:
Potable Water Source
& Type
is well 1 ❑ Spring 0 Stream or Creek
0 Cistern
0 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. 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.
Property Owner Print and Sign
4/20/2020
Date
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
$123.00
Total Fees: 4
3
Fees Paid: $123.00
Building Permit
OWTS Permit:
SEPT -04-20-6234
Issue Date:
/ 13 A l z_c
Balance Due: , r -Z
(�
Garfield County Public Health
Department: • /� / ` i t 5/(/ Zaeo
Signed Approval Date
PD. $123.00, CC, 4/20/2020