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HomeMy WebLinkAboutApplicationGarfield County 195 W. 14th 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 8 New Installation ❑ Alteration ❑ Repair BUILDING USAGE TYPE _-9Dwellin ❑ Tra:ns.Ient Use ❑ Comm./Industrial ❑ Non -Domestic 11 Other Describe -- --- INVOLUfD PARTIES I Property Owner: BUREAU OF LANG MANAGEMENT Phone: i - Mailing Address: 2300 RIVER FRONTAGE ROAD SILT, CO Bi 862 Email Address: Contractor: TEP ROLhy Maunleln LLC Phone: ( 970 296.9377 Mailing Address: PO80KVC, Parscnuts,CC81835 Email Address: KMclntothaiarraap com l BHoterdatelraep.com Engineer: Fox Enpineednp SoVlone, Inc. Phone.: ( 970 .250-5505 T Mailing Address: 670 Canyon Greek Crne. Grand Junctfar. CO 87507 Email Address: ooloradafox®hresnan net PROJECT LOCATION AND DESCRIPTION Job Address: RU31-17Pad Assessor's Parcel Number: 20306100900 Sub. Lot 6JAR Block Building or Service Type: Small Temporary Emplayee Housing #Bedrooms: 7 Garbage Disposal(Y/N) N Distance to Nearest Community Sewer System: NA Was an effort made to connect to the Community Sewer System: NA Potable Water Source ❑ Well ❑ Spring ❑ Stream or Creek i ❑ Cistern & Type © Community Water System Name Cltyof Rifle Garfield County Public Health Department – work)ng 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 th equired information which is correct and accurate to the best of my knowledge. , Property caner Print and Sign Date OFFICIAL USE ONLY 9 SA*- CC oa z—o'M special Conditions: Permit Fee: Total Fees: Fees Paid: Building Permit A/ OWTS Permit: Issue Date: Balance e: � FE- 7/r Garfield county Public Health Department: v` Signed Approval Date