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HomeMy WebLinkAboutApplicationEC Garfield County 195 W. 14ti' 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 ® New installation ❑ Alteration ❑ Repair BUILDING USAGE TYPE ® Dwelling ❑Transient Use ❑ Comm./Industrial ❑ Non -Domestic -- 1 ❑ Other Describe INVOLVED PARTIES �— Property Owner:_ herman M ul er & Janice JamesTa,t_Phone: ( 303)907-5511 Mailing Address: 230 Overlook Rd Carbondale, CO 81623 Emai[ Address: shermanVC&me.com -- -- .... _. Contractor: 1. A• 5edgwick, Inc phone. 970)948-1890 Mailing Address: P.O. Box. 10251 Aspen, CO 81612 Email Address: beniasedgwick@yahoo.com Engineer: OA e 0 o Address: �L T 5'�. �, -- - Phone: (z-k )-y ] 34+ Marlin g 'Z�I GrSv�++� Email Address: L /0 _ . - C ,� 0_ e` f lG` . U �. "�t�� l c� (fly i4 lea 1 •Conn_ _ PROJECT LOCATION AND DESCRIPTION Job Address: 184 Clipper Place Carbondale, CO 81623 Assessor's Parcel Number: 239 129 105 024 Sub. Stirling Rnach Lot 24 Lot Block Building or Service Type: Single Family home iiBedrooms: Pour garbage Disposal(Y/N) Yes Distance to Nearest Community Sewer System: Not Applicable/ Not feasible Was an effort made to connect to the Community Sewer System: Not feasible Potable Water Source 11 Well 0 Spring ❑ Stream or Creek © Cistern Type Eil Community Water System Name Stirilpq Ranch Water S stem s 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 informations which is correct and accurate to the best of 91- knowl��ge. ) � � Qimad a N I e- et- Property Owner Print and Sign Date OFFICIAL USE ONLY 'Pd 123.C C o`/al/l."i Special Conditions: Permit Fee: *123 00 Total Fees: # I:3.0 Fees Paid: 41 Z3. Building Permit OWTS Permit: Issue Date: Balance Due: , 6 ARE - 69 3 se ;P T- 49 3'7��Zd y J(rx+ ZZ, Garfield County Public Health Department: r Signed Approval Date P.7