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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 0 New Installations14 4/7-T I BUILDING USAGE TYPE 0 Dwelling I 0 Transient Use I 0 Comm,/Industrial ,Other Describe in4"1 -c. �. Alteration I 0 Repair ❑ Non -Domestic INVOLVED PARTIES Property Owner: a-ro i-4- . O.4u k tot/1- 'done: ( C) i1) 1 —0 i 2-0 Mailing Address: 176 6,4 9"-i 27/'r) iatti C:.4 7 Email Address: 7 a tr)�-c ?-'W /. Cap r� Contractor: 2 -C.'..7 Com-- Phone: ( } See i '— r -J Age Mailing Address: Email Address: Engineer: /— SNY1 tm.Se)Af Phone: ( 97 N -r--~--/!30 Mailing Address: // fie% l i S x w/ 7 -ac) £;:/r1w(Ir.4 S it Email Address: lfC�/'-9 S ( — FYI C- f C—crvr -1 PROJECT LOCATION AND DESCRIPTION Job Address: /37J—}J cy)�iC11 j✓9-.e, "6 : 721 ( 60 el L.,f �-7 7. Assessor's Parcel Number: 77Z2JOI6o $ub. L�1.�1�-KlJ f v z. ar Lot -� Block Building or Service Type: en l r 7 .L L.7Ari' N #Bedrooms: $r Garbage Disposal(Y/N) 4% Distance to Nearest Community Sewer System: Was an effort made to connect to the Community Sewer System: �4" Potable Water Source Well ❑ Spring ❑ Stream or Creek ❑ Cistern & TypeCommunity Water System Name av 1fr3 %l�,"L 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 knowled Property Owner Print and Sign %z O OFFICIALIJSE ONLY Special Conditions: Permit Fee: I /46b0 Total Fees: /� 124 •V//�� Q Fees Paid: 11'/AAyI� .©p Building Permit eiLitk- oto OWTS Permit: csyr- Issue Date: 745z> 0,, Balance Due: Garfield County Public Health Department: �1��� /amuC� � / W - �� � 0 � / � Signed Approval Date PD.4 124.co, cc, k we Jai) ir,sls. Tri 114tin i