HomeMy WebLinkAboutApplication195 W. 14th Street
Rifle, CO 81650
(970) 625-5200
field County
Public Health
2014 Blake Avenue
Glenwood Springs, CO 81601
(970) 945-6614
OWTS PERMIT APPLICATION
TYPE OF SYSTEM CUNSTRUGTIOSI
Et New Installation j ❑ Alteration
BUILDING USAGE TYPE
21 Dwelling .1 ❑ Transient Use
❑ Comm./Industrial
Repair
( ❑ Non Domestic
0 Other Describe
INVOLVED PARTIES y�r•
y,
Property Ouia: 41.6n," irn Phone:(G) /ri ) i- in//-
Mailing Address:
.P6 gait Ilifi 5%L(?Mrt1M'SS et,.stasy
l
Email Address: `I dkeO,GOry / rc ef) dre3l/t'44; I. coot
Contractor:a- Phone: (
Mailing Address: Email Address:
Engineer: wlA.._Q
Mailing Address: ggiftIL61..--er'1I 0'' 8-7
Email Address: 41,viy.65431 d f.14`401r1
(Phone:( 1 la - �'7C5, __
(..srjaanj (c , 6 F14.a1
66s-t
PROJECT LOCATION -AND -DESCRIPTION--
lob woecP'I �]alvo g��2
Assessor's Parcel Number: 21 `dnviowt Sub. &MB by Eigjt46 tot a( Block
Uo I I
Building or Service Type: I�f51 ist'AZt/ #Bedrooms: g Garbage Disposal(Y/N) A
Distance to Nearest Community Sewer System: N /iP
Was an effort made to connect to the Community Sewer System: / Y eg
Potable Water Source
& Type
n Well
❑ Spring
❑ Community Water System Name
Garfield County Public Health Department working to promote health and prevent disease
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. 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 Owner,Print and Sign
Date
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
$123.00
Total Fees:
$123.00
Fees Paid:
$123.00
Building Permit
BLRE-05-20-6291
OWTS Permit:
SEPT-05-20-6292
Issue Date: 6/25/2020
Balance Due:
$0'00
Garfield County Public Health
Department: /� ��
A4. itV ?-"c, 67zq4eZe
Signed Approval Date
PD. $123.00, CC, 5/27/2020