HomeMy WebLinkAboutApplicationGarfield County
195 W.10' Street Public Health 2014 Blake Avenue
Rifle, CO 81650 Glenwood Springs, CO 81601
(970) 625-5200 (970) 945-6614
QWTS PERMIT APPLICATION
TYPE OF SYSTEM CONSTRUCTION
❑ New Installation
BUILDING USAGE TYPE
® Dwelling ❑ Transient:'Use
❑ Other Describe
❑ Alteration
❑ Comm./Industrial
M Repair
j ❑ Non -Domestic
INVOLVED PARTIES
Property Owner: TERRY DANKO Phone:( (/Q)HCE : 970-945-867 6
Mailing Address: 1602 GROVE STREET, BOULDER, COLORADO 80302
Email Address:
Contractor: DAVID RIPPY CONSTRUCTION, INC. Phone: (970 ) 945-0550 gtFs9 - 5',b�
Mailing Address: 3950 MIDLAND AVE STE F'-2 GLENWOOD SPRINGS CO 81601
Email Address: RAVE @ DRC INC . BI Z
Engineer:HIGH COUNTRY ENGINEERING, INC _ _Phone:( 970 } 945-8676
Mailing Address: 1517 BLAKE AVE SUITE 101 GWS CO 31601
Email Address: RNEAL@HCENG.COM
PROJECT LOCATION AND DESCRIPTION
job Address: 5 5 785 6& 2 4 HWY GLENWOO D SPRINGS COLORADO 81601
Assessor's Parcel Number: 218502100061 Sub. SUSTE 4 Lot 1 Block 0
Building or Service Type: OWTS #Bedrooms: 3 Garbage Disposal(Y/N) N/A
Distance to Nearest Community Sewer System: 1 r 4 5 0 FT
Was an effort made to connect to the Community Sewer System: NO
Potable Water Source! ❑ Well I ❑ Spring ❑ Stream or Creek ❑ cistern
& Type R Community Water System Name NO NAME
Garfield County Public Health Department —working to promote health and prevent disease
C£RTIFICATI0N,-.,_ 41:::-:. :.
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 of 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.
t . IV
Property 110ner Print and Sign ate
OFFICIAL USE ONLY ?,L V ?5.'O C K# 2- 3 S 9 a?fo��2� !
Special Conditions:
Permit Fee:
4-75'.
Total Fees:
$ 7S. °-a
Fees Paid:
4'75, cn
Building Permit
N/A
OWTS Permit:
SC PT'- Gq G°J
Issue Date:
Balance Due:
Garfield Loupty Public Health Department:
Signed Approval Date
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