HomeMy WebLinkAboutApplication195 W. 14th Street
Rifle, CO 81650
(970) 625-5200
Garfield County
Public Health
2014 Blake Avenue
lenwood Springs, CO 81601
1 (t (970) 945-6614
„j [ 71,
OWTS PERMIT APPLICATION
TYPE OF SYSTEM CONSTRUCTION
❑ New Installation 1 [i217 Alteration
BUILDING USAGE TYPE
Er Dwelling 0 Transient Use 0 Comm./Industrial [ 0 Non -Domestic
0 Other Describe 5-mm6r
0 Repair
INVOLVED PARTIES f
Property Owner: Rio t�iMCd /?4HCl'1 CdPhone: (tr
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Mailing Address: f •e •• BtX 75-0 / M / Co g/64/
Email Address: elekc e h 1/N feg ra ft C $ • COM �
Contractor: /.nni4Qrit. I�o*$ G\. Phone: ( 343 ) 92 9 — 6-144
Mailing Address: 3? g [.(i►'41 �5 C►r'� k 3Pr)✓C /Wel e j [o 'did 4f
.retinin9erlapho►r 5 � ya Of - Odin
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Phone: Email Address: ie
Engineer:�y74G� e: ( 7 " 27 Si—
Mailing
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MailingAddr�ess: 2-304 ' 7Th avc �v / ipiT Sq 7/5--
Email
/SEmail Address: )1/44644ESoh i'J7ya/'7'GGny • cem
PROJECT LOCATION AND DESCRIPTION
Job Address:
3650 TF4ppersL4 C Rea I M to g-14 4-1
Assessor's Parcel Number: /4ZI L 1$4- 00-001 Sub, WA \ Lot NI4 Block N4
Building or Service Type: gel ;0100:74; 01 Garbage Disposal(YIN)
#Bedrooms:
Distance to Nearest Community Sewer System: 54 miles
Was an effort made to connect to the Community Sewer System: Ne
4 -
Potable Water Source MWeil
& Type
0 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. 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 prov ' ed the required information which is correct and accurate to the best of
mykn
roperty Owner Print and Sign
Dale
OFFICIAL USE ONLY
Special Conditions:
Per
Total Fees:
Fees Paid:
_lice
Building Permit
0LP - (o2
OWTS Permit:
w'r (.3o3
Issue Date:
Balance Due:
Garfield County Public Health
Department:
Signed Approval Date
fp.* .b0, CCS(f3�2417_4
Pave 5 of 3
Updated Der 2013