HomeMy WebLinkAboutApplication195 W. 140h Street
Rifle, CO 81650
(970) 625-5200
Garfield County
Public Health
Public Health
2014 Blake Avenue
Glenwood Springs, CO 81601
{970) 945-6614
OWTS PERMIT APPLICATION
TYPE OF SYSTEM CONSTRUCTION
LIU New Installation
BUILDING USAGE TYPE
❑ Dwelling j 0 Transient Use
❑ Other Describe
INVOLVED PARTIES
�❑
Alteration
❑ Comm./Industrial
L ❑ Repair
❑ Non -Domestic
Property Owner: Alexandra SchwaIler
Malting Address: 277 Miler Ln., Rifle, CO 81850
Email Address: ahoti@sopris.not
Phone: ( g70 ) 274.6337
Contractor: Clayton Homes Phone. ( 970 ) 245-9039
Mailing Address: 671 23 Road Grand Junctron, CO 61505
Email Address: davld mahovsky(gclaytonhomes.com
g Kan Brosik ( 970 )I 216-8861
Engineer: r Phone:
Mailing Address:
Email Address: kbrotsky@yahoc.com
PROJECT LOCATION AND DESCRIPTION
Job Address: TBD Old Ranch Road Rifle, CO 81650
Assessor's Parcel Number: 212734300344 Sub. Ryden Ranch Exemption Lot 3 Block
Building or Service Type: Residence
#Bedrooms: 3 Garbage Disposal(Y/N) N
Distance to Nearest Community Sewer System: ovsr; mile
Was an effort made to connect to the Community Sewer System: Yes
Potable Water Source I B well ❑ spring 3 ❑Stream or Creek
& Type
0 Cistern
0 Community Water System Name
Garfield County Public Health Department — working to promote health and prevent disease
Alexandra schwaller
Property Owner Prfnt and Slip
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.furt1
hersre do that anyf anyfalsiranted bor ased upation on on aidaapplication result the and le all of the
action for perjury
application or revocation of permitgranted pg
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.
-uocuNanad oy:
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OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
1�,. vo
Building Permit
att1F- 0151
OWTS Permit:
-b3.31.
Garfield County Public Health Department:
Total Fees:
Issue Date:
Signed Approval
pit 12.3.001 cc, 11 r q j7.vzo
6/16/2020
Date
-76/z0'
I
Fees Paid:
Balance Due
12.3. o0