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HomeMy WebLinkAboutApplication195 W. 14th Street 16 urarJlela c,ounry Public Health 2014 Blake Avenue INIICj 4V UIUJU UICI IY4UUU .) JI IIIgo� l.V U�Vll J. OWTS PERMIT APPLICATION i Ir L !ON J i Ji V1s,i.i+Vyfdi!\Y4,. I r, BUILDING USAGE TYPE Dwelling 0 Transient Use 0 Comm./industrial 1 ❑ Non -Domestic ❑Other Describe r un imrs oeirrise Property Owner: Mailing Address: Email Address: 61441,E-A- `( -t3-6 OM r n n+r %rf n•• Email Address: Engineer: Mailing Address. £[rlall MUUrtSS: 61, Inn o• 1 c) a}is A .i l'i Onk.' re1aphone: ( 1 Ro 3 C2_ I 4 ,moo SP(1-045 D it l e_ lj J -- o M PROJECT LOCATION AND DESCRIPTION job Address: 3 e Z 3 Assessor's Parcel Number:ZJl Z-4) Obz l © Sub. Lot ~ Block Building or Service Type: , F . Q , flBedrooms: ' ' Garbage Disposal(Y/N) thstance to Nearest Community Sewer system: U rS 1c._ b_ror.) Was an effort made to connect to the Community Sewer System: h16 — 740 (44, Potable Water Source & Type well ❑ Spring ❑ Stream or Creek 0 Cistern ❑ community Water System Name Garfield County Public Health Department — working to promote health and prevent disease CERTIFICATION Annfirant acknowlpriges that the rmmnlptenp,ss of the annliratinn is cnnditinnal unnn such further mandatory and additional tests and reports as may be required by the local health department to be 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 d 1.JIJ11LdLIVI1 UI IeVUt dL1LIII V1 dily pel IIIIL gi iiidU Ud?ICU upt.nI SdIlU dpplli„dLIUtI dIIU ICgdl dL.LIUII IUI i.IelJUIy e nrniurir. l h" I-na, 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 �I b Cl � 1�Yl �ok0.1.Ct`yl Property Owner Print and Sign Sj/2/7O e OFFICIAL USE ONLY Cnnrfel rnnrlitinne• 1 fermit Fee: I?•3 _b0 Total Fees 3 ` �.o �v Fees Paid: $127 .00 Building Permit �J� SLUE- {013 OWTS Permit: SEIX- ((01g issue Date: izf '//J/ / // zc,Lc, Balance Due: Garfield County Public Health Department: Signed Approval 13D 4.'>j.cv J � t1 (z f 2a E- tzliy/26?ey Date Updated Dec 2013