HomeMy WebLinkAboutApplicationGarfield C'ouJ�ty
195 W.14'h Street Public Health 2014 Blake Avenue
Rifle, CO 81650 Glenwood Springs, CO 81601
(970)625-5200 (970)945-6614
OWTS PERMIT APPLICATION
TYPE OF., SYSTEM CONSTRUCTION
rl'rNew Installation I ❑ Alteration ❑ Repair
BUILDINaU AGETYPE _
❑ DwellingLL_Ld Tran ansi_e.n._t_U_se
❑ Comm./Industrial _Non Domestic
90ther Describe
INVOLVED PARTIES
Property Owne- �yPhone:(s��-•S"--•--
MallingAddress: AW.i�+/ IfiJrSa�.1 !'�-t�['ra.. e=rFja,_C�E 'fi'f (q'
Email Address: it-4 k-t„
Contract---cto�L4 C.�LIC.L,lr✓>��abVi.,nJs" Phone:( •�j�Goa%5'-."'✓�.O'%
Mailing Address v-71 „y po9J n2'I.-t�os� (,IFS �jCJ2
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Email Address: C'C" / b tom"' 41,04�61 ,,c
Engineer:lC.� Phone: ( %@ )
Mailing Address: 923 ra Ce 91(.01
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EmallAddress: 6cu[.: t2 6 w •-
PR OJECTLOCAMONANDDESCRIPTION_
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Job Address:. /,£s.' _4 /Jr/ tsca,.v-.-_-.C+v'r✓v -� /i/"1 C'
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Assessor's Parcel Number r y�HDy(�iI�Li Sub. Lot Black
Building or Service Type: �.. V 0 Niedrooms: GarbageDisposal(Y/N)
Distance to Nearest Community Sewer System: �uel 19 - n: ,.�'i 04T
Was an effort made to connect to the Community Sewer System: Ate) v, T� E2 &�
Ill
Potable Water Source
Well
❑Spring
❑ stream or Creek
Cistern
$ TYPe
❑ Community Water System Name _ - •�-
Garfield County Public Health Department - working to promote health and prevent disease
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CERTIFICATION
Applicant acknowledges that the completeness of the application is conditional upon such further
mandatary 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.
all
Property Owner Print and S161 Date
OFFICIAL USE ONLY
his..=! cc OS01 2'na l
Special Conditions:
Permit Fee:
$75.o0
Total Fees:
qS, cr
7
Fees Paid;
$?5.A..r
Building Permit
OwiS Permit:
Issue pate:
Balanc Du
N/A
S pr- L 4
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Garfield County Public Health Department:
Signed Approval Date
P.t;;e :"', 4-, f 3