HomeMy WebLinkAboutApplicationL95 W. l-4th Street
Rifle, CO 81650
(s70) 62s-s200
Public Health
RECEIVED
JAI¡ A 4 ¡fil"I
GARFIELD COUNTY
COMMUNITY DEVELOPMENf
2014 Blake Avenue
Glenwood Springs, CO 8L601
(970194s-661.4
OWTS PERM IT APPLICATION
Gørfield County
WPE OF SYSTEM CONSTRUCTION
Dß New lnstallation tr Alteration tr Repair
BUITDING USAGEWPE
R Dwelling E Transient Use El Comm./lndustrial tr Non-Domestic
E Other Describe
INVOLVED PARTIES
propefi g*n"r. CatheYMasseY Phone:( ane I ctx-zsts
Mailinc Address: 180 B Seebere Cir Carbondale. CO 81623
Email Address: cathey.massey@gmail.com
( 970 | 230-9082
Mailing Address:
Email Address:
715 GrandAve GSW CO 81601
office@mm-eight.com
)
Mailine Address:
Email Address:newkirkS6@smai.com
PROJECT LOCATION AND DESCR¡PTION
Job Address:TBD Wooden Deer Road Carbondale CO 81623
Assessor's parcer Numb er' 23e324304003 s"o.ï;'.',i,::ï::'å.i;H' -- lot--1-srock
-Building or Service Type: single family #Bedrooms: 3 Garbage Disposal(Y/N) y
D¡stancê to Nearest Community SewerSystem : N/A
Was an effort made to connect to the Community Sewer System : Ni A
Potable Water Source
& Type
tl Well fl Spring E Stream or Creek E cistern
H Community Water System Name \¡V'ooden l)eer S¡rhd ivision
Garfield County Public Health Department - working to promote health and prevent disease
Applicant acknowledges that the completeness of the application isconditional .gPo.n such further
nirin¿átorv and additTonal tests and réports as may be r'e(uired by the local healtl¡ department to be
mã¿e an¿ turnished bv the applicant or by the locàl health department for purpose of the evaluation of
the application; and ttie issuáñce of the pàrmit is subject to such terms and conditions as deemed
ñeceisàry to insure compliance with rulés and regulations made, information and-reports submitted
herewith'and required tó be submitted by the apþlicant are or will be represented to be true and
correct to the beit of my knowledge and belief and are designed to be relied on by the.local
department of health in'evaluatin[ the same for purposes of issuing the permit app[ied for herein. I
further understand that any falsifiıation or misrepresentat¡on may result in the deniaì of the
application or revocation of any permit granted bãsed upon said application and legal action for perjury
as provided by law.
I hereby acknowledge that I have read and understand the Not¡ce and Certification above as
well as have provided the required information which is correct and accurate to the best of
my *'W*
It'7g,^NJ
Property Owner Pr¡nt and S¡gn Date
Special Conditions:
Fees Paid:
{tz3."oI lz3..oTotal Fees:Permit Fee:j I 23.oo
Balance Due:.*dOWTS Perm¡t:
se?r- 7 zt &
lssue Date:Building Permit
øuz€,-1e81
Ga¡field County Publ¡c Health Department:
Signed Approval Date
t'age 3 ()l J
U¡rdaied lle¿ 2{tl3