HomeMy WebLinkAboutApplication195 W. 7.4a' Street
RIfIe, CO 81650 {
(970) 625-5200
Garfield County
Public Yealth;
2014 Blake Avenue
Glenwood Springs, CO 81601
(970)945.6614
OVNTS PERMIT APPLICATION
TYPE OF SYS f ENi CONSTRt1CTiUN � �,✓
0 New installation 0 Aiteration GY Repa:r
BUILDING UAGE TYPE
❑ Dwelling i 0 Transient Use Comm/Industrial ❑ Non Domestic
0Other Des�ribe '
INVOLVED PA**TiES - - -_
Property Owner IO -L ('SAS[ , 1 S rtf7tt �i:,,. Phone: (`
t 'rg
Mailing Address: t _I
EmaOAddress:{ tr):SG'lttic QOQL,fl ''vti._
Contractor: t Mailing Address:
' EmailAddress4
Engineer::.,'nes 4 G` O
!Balling ata _ it L° i
Emall Address;
PROJECT LOCATION AND DESCRIPTION
lob Address: '7�iii ,r
13913 0-P 10i�v"Su }seri otel r I, Lo ) Block
Assessor's Parcel Number, 1
Building or Service Type: C,tsinh 6lAe irer/T,: 1 i#Bedrooms: '""" Garbage Dlsposal(Y/N)..
Distance to Nearest Community Sewer System:. 1414
was an elfort{nade to connect to the Community Sewer System:
Potable Water Source LRrWell t7 Spring 0 Stream or Creek -. b Cistern
Community Water System Name
• /4
4
Phone:f7)05) 1 -1U2Gl
Se FL
a"1
s i i w e��llAr<
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PuU1ic Health
nt -, rrnc;:ii'tg tri }7Yi}n'K)te hofln grid prove[sense.
OERTiIRIiCATION
•
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. l
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.
%1/4222-3
Property Owner Print and Sign
7-, v5 --c3
Date
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
$123.00
Total Fees:
$123.00
Fees Paid:
$123.00
Building Permit
N/A
DINTS Permit:
SEPT -07-20-6396
Issue Date:
.0 V3 i / o7- p
Balance Due:
$0.00
Garfield County Public Health
Department: f ;3-'-(----0/ W. '7'--- -/
,
Signed Approval ,
Date
PD. $123.00, CC, 7/20/2020