HomeMy WebLinkAboutApplication195 W. 14th Street
Rifle, CO 81650
(970) 625-5200
Public Health
2014 Blake Avenue
Glenwood Springs, CO 81601
(970) 945-6614
OWTS PERMIT APPLICATION
TYPE OF SYSTEM CONSTRUCTION
❑ New Installation
BI�ILDlNG USAGE TYPE
Dwelling
❑ Other Describe
❑ Alteration Vf. Repair
❑ Transient Use
0 Comm./Industrial I 0 Non -Domestic
INVOLVED PARTIES
Property Owner: Michael Hayes and Sydney Schalit Phone: ( 970-M9-5006
Mailing Address: 11 RR f .nnnfy Rnarl 1(16 Carhonrialw CC) R16623
Email Address: mjhayesl5 a • '-'1.com
Contractor: Phone: ( )
Mailing Address:
Email Address:
Engineer: Carla Ostberq 1 Romeo Baylosis Phone: ( 970_109_575g
Mailing Address: 334 Wheel Drive Road, Carbondale CO 81623
Email Address: Carla 05tberO@groail cnm, rnmeOQrbcivil com
PROJECT LOCATION AND DESCRIPTION
Job Address: 1188 County Road 106 Carbondale CO 81693
Assessor's Parcel Number2393-2$3-08-015
Building or Service Type:
Distance to Nearest Community
Was an effort made to connect
SL(DOOPERTON TWNSTE. Lot 17 18 Block
8
N
single family #Bedrooms: 3 Garbage Disposal(Y/N)
Sewer
to the
System: N/A
Community Sewer System: No
Potable Water Source
& Type
Well
0 Spring 0 Stream or Creek
0 Cistern
jCommunity
Water System Name Satank Water Association
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.
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
051051 2020
Date
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
$123.00
Total Fees:
$123.00
Fees Paid:
$123.00
Building Permit
N/A
OWTS Permit:
SEPT-05-20-6259
issue Date:
6 6/` 6 /Z &Z O
Balance Due:
$0.00
County Public Health
Department: 14 I�4 `
G'�Garfield
�6/ / c'l i
q
Signed Approval /
Date
PD. $123.00, CC, 5/5/2020
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