HomeMy WebLinkAboutApplication195 W.14`h Street
Rifle, CO 81650
(970) 625-5200
I,
i
Public Health 2014 Blake Avenue
Glenwood Springs, CO 81601
(970)945-6614
.. 111, �.
TYPE OF SYSTEM CONSTRUCTION
❑ New Installation ❑ Alteration Repair
BUILDING USAGE TYPE
! — Dwelling ❑ Transient Use ❑ Comm./Industrial O Non Domestic
❑ Other Describe
Property Owner - hie/ C7 PS 05C. Iff
Mailing Address J l 1 � G.�� vTZ1.0,_C
3
EmallAddress: C w 0 ii U. ^ 7�--'
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contra tor: 0 0-44 � _^�__ P/��one: (�( )/"�3��7
I Mailint, Address: 150 �✓ ~n C wa
Emai I Ad d ress: %I/"7rtiYL70m, ff's G0l�i
Engineer: Phone: ( 1
Malling Address;
Email Address:
PROJECT LOCATION AND D DESCRIPTION i
�
iAssessoesParcel Number;
ROIT3SS gBiy, 32
Building or Service Type:[(
Distance to Nearest Community Sewer5ystem:
Was an effort made to connect to the Community Sewer System:
Potable Water SourceIarcwe
& Type ; -ff cor
R
❑ Spring ❑ Stream or Creek ❑ Cistern
1 Water System Name
Disposal(y/Q_
3arfield 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.
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 there ' d information which is correct and accurate to the best of
my knowledge.
Property Owner Print and Sign Date
OFFICIAL USE ONLY Ift. a' CC 05/24/262.1
Special conditions:
Permit Fee:
S '?-"
Total Fees:
4'75.0 °
Fe s Pald:
TT-00
Building Permit
OwTS Permit:
Issue Date:
-IZ
Balance Due:
N
3EVr - GSG,S
aJ-/J 667
Garfield County Public Health Department:
Signed Approval
Date