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HomeMy WebLinkAboutApplication195 W. 14th Street Rifle, CO 81650 (970) 625-5200 Public Health 2014 Blake Avenue Glenwood Springs, CO 81601 (970) 945-6614 OWTS PERMIT APPLICATION TYPE OF SYSTEM CONSTRUCTION N. New Installation ❑ Alteration 0 Repair BUILDING USAGE TYPE Dwelling 0 Transient Use 0 Comm./Industrial 0 Non -Domestic 0 Other Describe INVOLVED PARTIES Property Owner: 45(2:" /15on 2/4re Phone: (.670 ) 3 66 - ©ia3 Mailing Address: 1( (k cAse &: !a4 (-c?- bl4 a Email Address: i t:SSt*nr-47.Zzare. sti-K.O. Gnu Contractor: Mailing Address: Email Address: L;h74 -Phone: ( `T'7O) „rt./-gip /OM 6att1_ Crag t`cd. ,2d Gr6dt Co & )s`ev 36)117616w`'rl+..fr Engineer: Cap fry_ Mailing Address: Email Address: 3 :a- k4letl '» Pho:ne: ( TM-3 0 - 5oA5i Arica. on us 50,62 {_.CM PROJECT LOCATION AND DESCRIPTION Job Address: loiL I 6.M C:tk P14 PA (ow [e Co }'ray Assessor's Parcel Number: i{ Sub. Building or Service Type: Distance to Nearest Community Sewer System: Lot Block #Bedrooms: 3 Garbage Disposal(Y/N) y Was an effort made to connect to the Community Sewer System: Potable Water Source 1S' Well 0 Spring ❑ Stream or Creek �{ ❑ cistern & Type I A Community Water System Name l -•�h e f ir0i..4 Garfield County Public Health Department - working to promote health and prevent disease �' �� 5y0k4 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 h ve r and un 3rst d the Notice an Ce fication above as well as haveyrnui the re ed €n ch Is correct an r4W,g a t 7(../ my knowledge. U e i I ��&I)Yide/t‘—A—--< < i 0 Property Owner Print and Sign Dale OFFICIAL USE ONLY Special Conditions: Permit Fee: $123.00 Total Fees: $123.00 Fees Paid: $123.00 Building Permit BLRE-11-20-6595 DINTS Permit: SEPT-11-20-6596 Issue Date: Balance Due: $0.00 Garfield County Public Health Department: Anna Cochran 11/25/2020 Signed Approval Date PD. $123.00, CC, 11/19/2020