HomeMy WebLinkAboutApplicationGørfteld County
Puhlic Health
195 w. 14th street
Rifle, CO 81650
(970) 62s-s200
20L4 Blake Avenue
Glenwood Springs, CO 8L601
(970) e4s-6614
OWTS PERM IT APPLICATION
TYPE OF SYSTEM CONSTRUCTION
tr Alteration tr RepairE New lnstallation
B Dwellin Non-Domestictr Comm./lndustrial[] Transient Use
BUITDING USAGE WPE
E Other Describe
Email Address richard@nashænstructlôncompâny.com
'965 Westbank Rd. Glèruæd Springs, CO 81601
Rlchârd ånd Nash
dress
INVOL
Contfactof : ownBf constßcted PhOnel 970 379-5172
Mailing AddreSS: same
Email Address: same
Mailing Address:502 Ma¡n Str€el, Sults 43, Carbondale, CO 81623
Sopris 0o¿ l03l IPaul Rutlsdge & Yancy N¡chol
Email AddfeSS: prutledgs@sopri6eng.@m
ASSeSSOf'S parCel N U mbe¡¡ 21853s30r015 SU b. Westbank Ranch subdiv¡sion #1 tot Lor]l_BlOCk _
Building or Service Type:Res¡dent¡al #Bedrooms:3 Garbage Disposal(Y/N)¡9_
Was an effort made to connect to the Community Sewer System:
Job Address:965 Weslbank Rd, Glsnwood Springs, CO 81601
D¡stance to Nearest Community SewerSystem:> 2 mile
N/A
PROJECT TOCATION AND DESCRIPTION
E Stream or Creektr Well E Spring E GsternPotable Water Source
&Type E Community Water System Name \ryþst Bank \ þter
Garfield County Public Health Department - working to promote health and prevent disease
I
Aoolicant acknowledges that the completeness of the application is.conditíonal upon such further
;i#ää;ï;;¡;;¡üilileilt ãn¿ réportsas Fay.qe r'eiuired by the local health department to be
,ãäã
"îu'rùrn¡st
e¿ ¡v i-n" ã-pïrtåni ã? uvi¡" locál.health depardment forpurpos.e of th-e,evaluation of
iË".pö;;;ì;.;;ãlli" i;ilJñeıïiñ" pärrn'¡ is subject to srich terms and conditions asdeemed
necessarv to insure.orpliJ*ã*¡ttt-iulåt anã reguliiions made, information and.reports submitted
ffi;;ii";î;Ëqti';äiã'Ëîùu'Åüiåã ¡vir'Àap-pt¡'ant are or qill b5 rep.fesFl'!-eq l?be-true and
correct to the beit of my knowledge and belief and are designeclto be rel¡ed o.n þy tne.local
ı'ojffiã^ì ottoåñrt i. *åi,iåliñËitrã sj-. for purposes oiissuing the.permit a.RRlied lor herein. I
iutttrei understand that any falsifiiation or misrepresentation may result an the denlal c)1 tne
;;;iË¡o¡ãirãuJ.ät¡on äï áñl pãiräit granted Ëased upon said a'pplication and legal action for perjurv
as provided by law.
CERTIFICATION
I hereby acknowledge that t have read and understand the Notice and Certification above as
well as have provided the required information which is correct a¡td accurate to the best of
my knowledge.
57Ç-z/Ãotu"?
Property Owner Print and Sign Date
Pad O312812021 5123.00
OFFICIALUSE ONLY
Speclal Conditions:
Fees Paid:
$r23.oo
Total Fees:
9113.oo
Permit Fee:
$123.00
Balance Due:
$o.oozù'¿
lssue Dater
ú
OWTS Permit:
sE PT-6880
Eullding Permit
N/A
f. tr_
Garfield County Public tlealth Department¡
Signed Approval
,t6,/a'//2",ap
Date