HomeMy WebLinkAboutApplicationf, Garfield County
195 W. 141h Street lqmw public Health 2014 Blake Avenue
Rifle, CO 81650 Glenwood Springs, CO 81601
(970) 625-5200 (970) 945-6614
DINTS PERMIT APPLICATION
TYPE OF SYSTEM CONSTRUCTION
® New Installation ❑ Alteration f ❑ Repair
BUILDING USAGE TYPE
® Dwelling 10 Transient Use ; ❑ Comm./industrial ❑ Non -Domestic
[]Other Describe
INVOLVED PARTIES
Property Owner: Thad and Morgan Porter Phone:l 970iQ1fi_-Z]27
Mailing address: 4700 CR 314, New Castle, Colorado 81647
Email Address: porter thad@yahoo.com
Contractor: Thad Porter Phone: ( 970)618-7727
MallingAddress: Same as above
Email Address:
Engineer. Jeff Simonson, PE, SGIVI-Inn Phone: ( 970) 945-1604
Mailing Address: 118 W. 6th Street, Suite 200, Glenwood Springs, CO 81601
Email Address: Jeffs@-sgm-inc.com
PROJECT LOCATION AND DESCRIPnM
JobAddress: TEID. S6, T6S, On Lots 6 & 6, CR 244, Rifle, Colorado
Assessor's Parcel Number. 217706200041 Sub. Lot 5&6 Block
Building or service Type: Single Family #Bedrooms: 5 Garbagealsposaljy/NI N
Distance to Nearest Community Sewer system: 1 + miles
Was an effort made to connect to the Community Sewer System-. No
Potable Water Source ❑ well ❑ Spring ❑ Stream or Creek G4 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 bylaw.
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.
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Property Owner Print and Sign ate
OFFICIAL USE ONLY P1 I Z3. o e K r!:' SyS
Special Conditions:
Permit Fee:
* 12 3. qv
Total Fees:
# 123 . Sz-
Fees Paid:
.$ 123. UL
Building Permit
oWTS Permit:
Issue Date:
0
Balance Due:
4ArI
seer-G$s2
Garfield County Public Health Department
Signed Approval
Date