HomeMy WebLinkAboutApplicationGurfield Coanty
Public Heulth
i-95 w. 14th street
Rifle, CO 81650
(970) 62s-s200
2014 Blake Avenue
Glenwood Springs, CO 81601-
(970) 94s-66r4
OWTS PERMIT APPLICATION
TYPE OF SYSTEM CONSTRUCTION
tr New lnstallation tr Alteration ø Repair
BUITDING USAGE TYPE
ø Dwelling E Transient Use tr Comm./lndustrial tr Non-Domestic
E Other Describe
INVOTVED PARTIES
Property Owner. candace and Daniel Dixon Phone (970 ) 948-6897
Mailing Addre5S; 2395 State Highwav 133 Carbondale Co 81623
Email Address:ddaco@rof.net
Contractor:Custom Works lnc I 970 I 948-6897
Mailing Address:PO Box 508 Carbondale CO 81 623
Email AddreS5; dan@custom-works.biz
Eng¡neer: carla ostbergiRomeo A Baylosis PE Phone:( 970 ) 30s-525s
Mailing Address:129 Cains Lane Carbondale CO 81623
Email AddreSS. carla.ostberg@gmail.com
PROJECÍ LOCATION AND DESCRIPTION
Job Address:2395 State Highway 133 Carbondale CO 81623
Assessor'sParcelNumber'2463-034-00-002 sub.
-Lot-Block
Building or Service Type: Residential #Bedrooms: 4 Garbage Disposal(Y/N)
Distance to Nearest Community SewerSyste m. 1/4 mile
Was an effort made to connect to the Community Sewer Syste m: yes/ Moratorium outside Carbondale city limits
Potable Water Source
& Type
tr well tr Spring E Stream or Creek E Cistern
E Community Water System Name Carbondale City Water
Garfield County Public Health Department - working to promote health and prevent disease
--'-1
Applicant acknowledges that the completeness of the application is.conditional.upo.n such further
n'ia'ndatory 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 tlie issuá¡ice of the permit is subject to such terms and conditions as deemed
neceésãry to insure compliance with rulés and regulations made, information and.reports submitted
herewith'and required tò be submitted by the apþlicant are or will be represented to be true and
correct to the belt 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 falsifiıation 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,
CERTIFICATION
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.
2anà/12t14t2021
Property Owner Print and Sign Date
OFF| CIAI USE ONLY 7¿ .t'lJ oo ê. c.r2fslzoz( ¿5;tÐ
Special Condit¡ons:
Perm¡t Fee:+7f . oo
Total Fees:
å 1S.o'Fees Paid:
{ -1S,.ô
Building Permit
x/¡
OWTS Permit:
sePT- 1L7 Z
lssue Date:Balance Due: ,+ø
Garfield County Public Health Department:
Signed Approval Date
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