HomeMy WebLinkAboutApplication195 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
1N Dwelling J C1 Transient Use
❑ Other Describe
Alteration 0 Repair
0 Comm./Industrial
0 Non -Domestic
INVOLVED PARTIES
Property Owner: Harry & Kathryn Peisach
Mailing Address: P.O. Box 739, Snowmass, CO 81654
Phone:( 970 )920-7554
Email Address: harry@ski.com
Contractor: WRW Log Works Phone; ( 970 ) 2744412—
Mailing Address: 1009 Cattlecreek Ridge Rd. Carbondale, CO 81623
Email Address: wrw3@hotrnail,coin
Engineer: Silvertown Structures
Mailing Address: 307N AABC Aspen, CO 81611
Phone: ( 970 ) 300-I003
Email Address: meeger20@sopris.com
PROJECT LOCATION AND DESCRIPTION
Job Address: TBD Carbondale, CO 81623
Assessor's Parcel Number: 2393014011008 Sub. Ranch at Coulter Creek PLR 8 Block
Budding or Service Type: Residential #Bedrooms: 4 Garbage Disposai(Y/N) Y
Distance to Nearest Community Sewer System:
N/A
Was an effort made to connect to the Community Sewer System:
Potable Water Source
& Type
❑ Well ❑ Spring
0 Community Water System Name
N/A
0 Stream or Creek
0 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 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.
12424:21L"A
Property Owner Print and Sign
Date
OFFICIAL USE ONLY
Special Conditions:
Perr It Fee:
f 123•oo
Total Fees:
123.00
Fees Paid:
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Building Permit
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QWTS Permit:
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Issue Date:
10/21/2020
Balance Due:
Garfield County Public Health
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Department: /: 1 "\ ()( 1,---(-,------
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Signed Approval Date
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