HomeMy WebLinkAboutApplicationDistance to Nearest Community SewerSystem:'
Was an effort made to connect to the Community Sewer System:
Potable Water Source 0 Well 0 spring ❑ Stream or Creek
& Type Community Water System Name
195 W. 14th Street
Rifle, CO 81650
(970) 625-5200
Garfield County
Public Health
2014 Blake Avenue
Glenwood Springs, CO 81601
(970) 945-6614
OWTS PERMIT APPLICATION
TYPE OF SYSTEM CONSTRUCTION':
❑' New installation
BUILDING USAGE TYPE
Dwelling 0 Transient Use ❑ Comm./Industrial I 0 Non -Domestic
❑ Other Describe
0 Alteration
0 Repair
INVOLVED PARTIES
Property Owner: Lan kSv Cin r Phone: (DO1 ) 5S13 -i2 5Q L ,
Mailing Address: "back. r 2 taoc\ cynric,Js C'J ), 4slta°l
Email Address: % r-c, �� (r��( `�h i �(:\\ \ ("Q frt
Contractor: '2a l...tOV2L Y_'1C Calfc' .4t r icii `_Phone: (C I )
Mailing Address: C .n . 4Jox Y�Cy ! 1...�C'�Un( \G ` co RI (Pa
Email Address:
Engineer:
Mailing Address:
Email Address:
Phone:(
PROJECT; LOCATIONANDDESCRIPTION . `'t
Job Address: ,`�r�l Urn r ia(^ (�\t�y� k co . nx)
Assessor's Parcel Number:o(rl ► N05C01Sub � OS$%Lot 1 Block_
Building or Service Type: Qeatakttlkl2 #Bedrooms: '3 GarbageDisposal(Y/N)
❑ Cistern
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
al herein.
department of health in evaluating the same for purposes of issuing the permit applied
fofurther 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.
! hereby acknowledge that l 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.
lL,-,.l� CDC 6/1092 0
�
Property Owner Pr nt and Sign Date
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
$75.00
Building Permit
N/A
Total Fees: $75.00
OWTS Permit: issue Date:
SEPT-09-20-6506
Garfield County Public Health Department:
PD. $75.00, CC, 9/22/2020
9/24/2020
Fees Paid:
Balance Due:
$75.00
$75.00
0