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195 W. L4th Street
Rifle, CO 81650
(970) 62s-s200
Public Heølth
OWTS PERM IT APPLICATION
TYPE OF SYSTEM CONSTRUCTION
X New lnstallation
BUILDING USAGE WPE
X Dwelling
INVOTVED PARTIES
2Ot4 Blake Avenue
Glenwood Springs, CO 81601"
(e7o) 94s-661"4
! Other Describe
n Alteration Repair
n Transient Use ! Comm./lndustrial n Non-Domestic
( 9521240-1106
Mailing Address 414 AABC Unit A, Aspen, CO 81611
Emait Address: Riley@logeproperties.com
GørrteH County
Mailing Address
Email Address:
e u
1129 Grand Avenue Glenwood S fln S
dale@kaupengineering.com
one: ( 9701945-9613
co 81601
onsu hone: ( 970|948-0935-
chad@yatescc.com
onContra
Mailing Address
Email Address:
n CisternX well n Spring n Stream or CreekPotable Water Source
& Type n Community Water System Name
PROJECT TOCATION AND DESCRIPTION
Job Address:
Assessor's Parcel Numb er:2391-321-00-013suU. Lot Block
Building or Service Type:Sing le Familv #Bedrooms: 4 Garbage Disposal(Y/N¡ Y
Distance to Nearest Community SewerSystem:> 5 miles
Was an effort made to connect to the Community Sewer System:No
Garfield County Public Health Department - working to promote health and prevent disease
Applicant acknowledges that the completeness of the application is.conditio.nal upon such further
niandatory and addiironal tests and réports as may be required by the local health department to.be
made and'furnished by the applicant or by the locál health department for.purpose of the evaluation of
the application; and tlie issuárice of the permit is su.bject to such terms and conditions as deemed
neceésäry 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 rep.resented 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 a.pplied for herein' I
fuither 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.
CERTIFICAT¡ON
l 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.
Ri Sode 6/6/22
Property Owner Print and Sign Date
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L'¡rrì:ifrri I jre l(i f .1
oFFtctAL usE oNLY PAtÞ * tz3.oo q¡1.+ 13ß ot-r/a- /zozz &
Special Conditions
Permit Fee:
$ t¿g.*
Total Fees:
* rzg.æ
Fees Paid:
S lz3.ca
Building Permit.
ß rÉ€- 1s("8
OWTS Permit:
sePT- 15'61
lssue Date Balance Due:+d
Garfield County Public Health Department:
Signed Approval Date
6/22/2022
06/22/2022