HomeMy WebLinkAboutApplication195 W. 14th Street
Rifle, CO 81650
(970) 625-5200
Pub Public! Health
2014 Blake Avenue
Glenwood Springs, CO 81601
(970) 945-6614
OWTS PERMIT APPLICATION
TYPE OF SYSTEM CONSTRUCTION
l New Installation ❑ Alteration ❑ Repair
BUILDING USAGE TYPE
Q Dwelling ❑ Transient Use 0 Comm./Industrial 0 Non -Domestic
0 Other Describe
INVOLVED PARTIES
Property Owner: EVAN SCHREIBER
Mailing Address: 337 KENT AVE 44A BROOKLYN, NY 11249
Email Address: Ivan@lightboxdevelopnent.com
Phone: ( 917 ) 960-5666
Contractor: RWI LLC Phone: ( 970
Mailing Address: 2579 COUNTY RD 115 GLAENWOOD SPRINGS, CO 81601
Email Address: ryanivy6@gmail.com
274-2422
Engineer: CB0 INC. Phone: ( 970
Mailing Address: 33 FOUR WHEEL DRIVE ROAD CABONDALE, CO 81623
Email Address: carla.ostberg@gmail.com
309-5259
PROJECT LOCATION AND DESCRIPTION
Job Address: TBD MEADOW CIRCLE CARBONDALE, CO 81623
Assessor's Parcel Number: 239106301010 Sub RANCI-1AT COULTER CREEK PULtot 10 Block
Building or Service Type: RESIDENTIAL #Bedrooms:
4
Garbage Disposal(Y/N)
Distance to Nearest Community Sewer System: NIA
Was an effort made to connect to the Community Sewer System:
N/A
Potable Water Source
& Type
❑ Well
❑ Spring
❑ Stream or Creek
El Cistern
® 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 provided the required information which is correct and accurate to the best of
my knowledge.
Evan Schreiber
CTAz 3c1t4.. .2/6 9-24-2020
Property Owner Print and Sign
Date
OFFICIAL USE ONLY
Special Conditions: jj L_ k 1 1 I
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Permit Fee:
` ! r
Total Fees: I i 3
Fees Paid:
Building Permit
a-E/10 j JD
OWTS Permit:
5 41r-10c32
Issue Date:
Balance Due:
44,
Garfield County Public Health
Department: 1 Odc ,/20
Signed Approval D to
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