HomeMy WebLinkAboutApplicationGarfield County
195 W. 14th 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 _
BUILDING USAGE TYPE
IR Dwelling 1 ❑ Transient Use
❑ Other Describe
T ❑ Alteration ❑ Repair
E Comm./Industrial ❑ Non -Domestic
INVOLVED PARTIES
Property Owner: TEP ROCKY MOUNTAIN LLC Phone: ( 1270 ) 285-9377
Mailing Address: PO Box 370, Parachute, CO 81635
Email Address: KMGntosh@terraep.mm l BHotard@terraep.com
Contractor: TEP Rocky Mountain LLC Phone: (970 ) 285-9377
Mailing Address: PO Box 370, Parachute, Co 81635
Email Address- KMclntosh@terraep.com/BHotard@terraep.com
Engineer: Fox Engineering Solutions, Inc Phone: ( 970 250-5505
Ma Iling Address: 570 Canyon Creek Drive, Grand Junction, CO 81507
Email Address: coioradofox@bresnan-net
PROJECT LOCATION AND DESCRIPTION
Job Address: GR 14-28
Assessor's Parcel Number: 2W1-332-00-019 Sub. Lot Block
Building or Service Type: small Temporary Employee Housing #Bedrooms: a Garbage Disposat(Y/N) N
Distance to Nearest Community Sewer System: NA
Was an effort made to connect to the Community Sewer System: NA
Potable Water Source ❑ Well ❑ Spring ❑ Stream or Creek ❑ Cistern
&Type 1 Q Community Water System Name 0411yefRifle
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 orwill 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 i r e t and accurate to the best of
my knowledge.
Property Owner Print and Sign ate
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
$75.00
Total Fees:
$75.00
Fees Paid:
$75.00
Building Permit
NIA
OwTS Permit:
SEPT-7063
Issue Date:
Balance Due:
$0
Garfield County Public Health De artment:
Signed Approval
Date