HomeMy WebLinkAboutApplication195 W. 14th Street
Rifle, CO 81650
(970) 625-5200
Garfield County
Pteblie Health
2014 Blake Avenue
Glenwood Springs, CO 81601
(970) 945-6614
OWTS PERMIT APPLICATION
TYPE OF SYSTEM CONSTRUCTION
0 New Installation 0 Alteration $ Repair
BUILDING USAGE TYPE
121
Dwelling 0 Transient Use 0 Comm./Industrial 0 Non -Domestic
0 Other Describe
INVOLVED PARTIES
Property Owner: 0? le.A trog M/51/0,4( Phone: ( ?'70) 377 - 703/
Mailing Address: 170 73 Cocer- Ro /IP nig criZi Co, e -P/C 5:2
Email Address: tic: A
rip co fry shzv atl(hirle: (fit)
Contractor /V? L es
Mailing Address: / A. 77 ciR 2/ apieevivoace9 Co,
Email Address: C.0 Jp ,Cf 0 m frit; • c m
Engineer:C is.LA tl alert, C Poriphone: ( 770 ) 3 o -5;25-9
Mailing Address: qgjCakiiffiative8-? c A PI)Or—laill-e Co F/412-3
c /*tit- of e 6/7 /9. i I e COrn
Email Address:
PROJECT LOCATION AND DESCRIPTION
Job Address: 3/497-? co k tdy tRoiW 1/ £115 C. oa/is-2
Assessor's Parcel Number:1 ) 72- al 0 it!). 4' EOM 4clis Lot Block
Building or Service Type: 1-e,..r 7 teem ft/4- 413edr oms: I/ Garbage Disposal(Y/N)
Distance to Nearest Community Sewer System: Was
—
Was an effort made to connect to the Community Sewer ystem:
At
Potable Water Source X Well El Spring 0 Stream or Creek 0 Cistern
& Type 0 Community Water System Name
CERTIFICATION
Applicant acknowledges that I he conVieteness of 1he applkason is conditional upon such further
mandatory and additional tests and reports as Wray to required by rise It al Iteallki department to be
made and 'furnished by the applicant Of by the lural health department r purpose .i the evaluation of
the applrc'S¢ihn. aub d the isst mice ci! 11ie pe.unit is subject to such terms arid cared trans a"5 deemed
necessary to insure €oirlpiiance with rules and re'grtix ilicins made, iniorkriatin.ri and ter -tins -Submitted
hermith and retluired to be submitted b the applicant are or will be represented to be lfue 3iird
correct 10 the hast of my knowledge and belief and are k eic1 to be relied Ou try the total
depnlinent of health in evaluating the carne for purposes of irx .vii ; the per ink applied far herein. 1
further understand that any falsifir.ationeh eri4sreprewrdblion may result in the denial of the
al>,ptication or revocation of any petrol.; granted best upon sad ;tpp' icahon attd legal action for pan try
as provided by law
f
hereby J.tigilovAqtge That t have read aid wiri,derstaiad tette Notice and Cerner' allon above fats
well &Shave prarr.ded i:tte- I netuircd Information which is correct andaccurate to tie best of
my F etawkd1 t
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Property Queer Print and Sign
OFFICIAL USE ONLY
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