HomeMy WebLinkAboutApplicationGørrteM County195 w. 14ú StreetRifle, CO 81650(970) 62s-s200TYPE OF SYSTEM CONSTRUCTIONF New lnstallat¡onBU¡I.ÐING USAGE TYPEtr Dwelling E Transient UseE Other Describetr Comm./lndustrial2014 Blake AvenueGlenwood Springs, CO 81601(970) 94s-6614tr Non-DomesticPublic HeøIthOWTS PERMIT APPLICATIONn AlteretionüRepairINVOLVED PARTIESPropertyOwner: ll-'i¿6 a,r.y' d¿n,r,{,r Lah.a Phone:lqz¿ lqç1 -7etL--?-'ii-MailingAddress: 2Lo fit<t y,tâo lT 1;-+ (o it¿,czEmail Address:Mailing Address:Email Address:I a7o I QHÇ^*ctCMailingAddress: lin î.ìlalú. A,,ta¿--. 4,,*t lol Gb¡¿¿,tJ -;{t;,tl< ftt lla¿¡tEmail Address:PRO'ECT LOCATION AND DESCRIPTIONJobAddress: 5un!,{fãl+ þaÅ 5¿t+ rd *ta52Assessor's Parcel Number:ftlï3Sloøzo ïub.Ê,r{,t¿y 1,ú¡¿r;,* Lot Block-Bullding or Seruice lyper k{i¿r+tht Sf Fiarh( #Bedrooms: jl Garbage Disposal(Y/N)Distance to Nearest Community SewerSystemlWas an effort made to connect to the Community Sewer System:AaPotable Water Source E Well tr Sprlng E Stream or Creek tr Cistem& Type E community water System NãmeGarfield County Public Health Department - working to promote health and prevent disease
Aoplicant acknowledges that the completeness of the application isconditional upon such further;ri-#ü;r.fi;;¡-;ã¡tñilitäiiiãn¿ rdportsas Fay.Þe ri:iuired bythe local health departmentto be;iil;;;à'fùinisttãà uv üË'e ãp-pt¡Cårt ã? uvit e locåltrealth depardment for.purpo.se of the evaluation ofiË;ñii;nil; äÀu Ííe iil"itüJıf trre pårmit is subject to sdch terms and conditions as deemednecessarv to insure.ompllancãwith rules and regulations made, information and.reports submittedËä;''iü;ï.l!i;ìË-d lä ñ iruriti"ã by the apilicant are or will be represented to be true andcorrect to the be;t of mV knowledge and belief and are designed to be relied on by the.locajıäñiliıihiãÈtr in'evatuatinfthe same for purposes oi issuing the.permÍt apntie.d lor herein. Ifuither understand that any falsification or misrepresentat¡on may result ¡n the denial of theàËËiLäti"" óiiðuocàt¡on of any permit granted based upon said application and legal action for periuryas provided by law.CERTIFICATIONI hereby acknowledge that I have read and understand the Notice and Certification above aswett as have provided the required information which is correct and accurate to the best ofmy knowledge.-2PropertyPrint and SignDateOFFtCtAt t SE Or,tLYá¡ * ii¡.qt ce a3/rr/r,ortSpecial Conditions:Fees Paid:ll¿t.?3Bal¿nce Due:-e-Garfield County Public Health Departmênt:./1tl&nt:'tr/e?/zce¿DateSigned ApprovalTotal Fees:lssue Date:d1,/a'/za z ¿OWTS Permit:Sefr'64î6"iiï'.*Building PermitBLRê- ô?5S