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�W Public Health19S W. 14"' Street 2014 Blake Avenue
Rifle, CO 81650 Glenwood Springs, CO 81601
(970)625-5200 (970)945-6614
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INVOLVED PARTIES
Property Owner:, MeganGeriseandEvanWinn Phone:(970-37y-7566
Mailing Address: 16724 Flwy 82. ,Carbondale. C081623
Email Address: me68ncerise@gmall,com
Contracton WOO 5octorConstructfon Inc p�nn`e "( b""' aT I
Mailing Address: Ann Qak Run Boad rarhnndaln r,_ n
Email Address: brucehranso rp is.net
Engineer: Odisea Consulting Engineers Phone: (.970 1527-9540� T"
Mailing Address: P.O. Box1809 Paonia CO81428
Email Address: leff@odiseanet,com
PROJECT LOCATION AND DESCRIPTION _
Job Address: 16724 Hwy �,s r ndal CO--- ——_____-
Assessor's Parcel Number: 239132202002 Sub. Cerise Minor Subdivision Lot 2 Block _
Building or Service Type: R-3 gBedrooms: 3 Garbage Disposal(V/N) n1.5
Distance to Nearest Community Sewer System: _SMiles
Was an effort made to connect to the Community Sewer System: Yes
Potable Water Source 13 Well ❑ Spring ❑ Stream or Creek ❑ Cistern
Type ❑Community Water System Name
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 knowledge.
5/6/2 1
Property Owner Print and Sign Date
OFFICIAL USE ONLY PA 4 (23.a0 ce—
Special Conditions:
Permit Fee:
112 S ��='
Total Fees:
l23
Fees Paid:
4
Building Permit
OwTS Permit:
Issue Date:
06le2
Balance Due:
#�
SL.M&G$41
seer-(o%47-
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Garfield County Public Health Department: / fl/ ✓ lL- - (��llZcz[
Signed Approval Date
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