HomeMy WebLinkAboutApplicationRECEIVED
GARHELD COU. "Y
EC-Crarfield Cou ;�—ty I GOINM'UNITV DEVELOPco d,r
195 W. 141h Street Public Health 2014 Blake Avenue
Rifle, CO 81650 Glenwood Springs, CO 81601
(970)625-5200 (970)945-6614
F e a L..e e L O
TYPE OF SYSTEM CONSTRUCTION
❑ New Installation epair
BUTLOING USAGE TYPE
❑ Dwelling ❑Transient Use ❑ Comm./Industrial -} ❑Non -Domestic
❑ Other Describe
j MaillngAddress:,atffq C l v� 0 V e
Email Address: Y. t e�.�, v h
- Contracter `I"re�l "1'Luf6_YQ Phone;(�,�jj 30q•1^%y�
MailingAddress:_
Email Address:,, S0,4.tt,J^i•rayE(1 I' �s19Wli.l f. Cow1
.,....._ -_ . e ..._
Engineer. "I& 6A ee, Qlkol time _._pho io: _ 36. h^2✓� .-._..
MalmgAddress: 33 'l Wheel Drive U Carkiin IKa CO Ifin
Email Address: Cy,d y Id.. , 0.1t birrir n aN141 Li011,1,
PROJECT LOCATION AND DESCRIPTION
lob Arklress: 191- CR Iltb, ��v�tl►11�, _8(/da l- _.. ..'. ....._. ._..._..... _,�,�,._. _�
i Assessor's Parcel Number, in3wo 0610 Sub V�ifA64*14kar Part).ot=j_Btock_
Building or Service Type: #Bedrooms: --_--Garbage Wmposal(Y/N)_
Distanre to Nearest CemmunnySewer System:
Was an effort made to connectto the Community Sewer System:
Potable Water Source ❑ Nell ❑ Spring I 0 Streamor Creek ❑ Cistern
...-..�._ ._._..—"_._A
&Type ❑Community Wafer 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 ar 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 ar 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 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.
Property Owner Print and Sign ate
OFFICIAL USE ONLY
Pd 4 T$, 4! C - 09 03/2QZ1
Special Conditions:
Permit Fee:
*?S.°b
Total Fees:
41s,.on
Fees Paid:
* 75.tao
Building Permit
DLRE- TO 22
oWTS Permit;
SEFr 7023
Issue Date:
C�� /i �c���
Balance Due:
Gar5eld County Public Health Department:
signed approval
gate