HomeMy WebLinkAboutApplication295 W.10 Street
Rifle, CO 81650
(970)625.5200
F—CiGarfield-County
Public Health
2014 Blake Avenue
Glenwood Springs, CO 81601
(970)945-6614
TYYPE OP SYSTEM CONSTRUCTION
Cal New Installation ❑ Alteration ❑ Re air
BUIU)ING USAGE TYPE
ki Dwelling ❑Transient Use _I ❑ Comm /Industrial 1 L Non -Domestic
❑ Other Describe
INVOLVED PARTIES . -
Mailing Address:M eat27, wno, co alesa..
Email Address-
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Contracton-4e`PPm0%—".yalryaoconauudwn Phone: (ero )easnxw
Mailing Address:
Email Address: ha4aaraaMae Ream."
Engineer:saPaaE006Mna,PaVIA0040aa6YomNldW Phone:(7g4 10311-__----
Malling Address: $ar Wn Meet 8"A3. oueaaeda, co arms
Email Address: PadaaseRaaa 0-"
Assessor's Parcel Number:2170rlOmI Sub. Ncaral6MrWMPRW Lot !2 61ock—
Distance to Nearest Community SawerSystem: '2096
Was an effort made to connect to the Community Sewer System: wA
Potable Water Source IR Welt I ❑ Spring I O Stream or Creek O 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 by law,
1 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 Date
OFFICIAL USE ONLY Pd 4 i 2 3 • "O CK *- 6 o g?9
Special Conditions:
Permit Fee:
S23 e"!
Total Fees:
4 1Z3.6-0
Fees Paid:
AiZ3." -
Building Permit
Owls Permit:
-703-7
Issue Date*
Balance Due:
�Eprt -
"
Garfield County Public Health Depart men�%
Signed Approval
Date
1-pdoped lice 21113