HomeMy WebLinkAboutApplicationGarfield County
RËCEIVED
GARFIEt-t) il {.,i i i ¡,.¡'i'.'
C0MMIJ!r'r:
Public Heulth
L95 w. l"4th street
Rifle, CO 81-650
(970) 62s-s200
2014 Blake Avenue
Glenwood Springs, CO 8L601
(970)94s-66r4
OWTS PERM IT APPLICATION
TYBE OF SVSTEM CONSTRUCTION
Ef New lnstallation tr Alteration tr Repair
BUILDING USAGE TYPE
Ø Dwelling E Transient Use tr Comm./lndustrial tr Non-Domestic
E Other Describe
INVOTVED PARTI
Property Own
Mailing Address
EmailAddress:
EmailAddress:
e:( )
Mailing Address:
Mailing Address:
EmailAddress:
PROJ ECT IOCATION AN D DESCRIPTIOIìI t
Building or Service Type: fBedrooms: Garbage Disposal(Y/N)-
Was an effort made to connect to the Community Sewer System:
rcel N Lot 2- Block
Distance to Nearest Commun¡ty SewerSystem
Job Addressr
Assessor's Pa
tr Spring El Stream or Creek E Cistern[Z.wellPotable Water Source
& Type E Community Water System Name
Garfield County Public Health Department - working to promote health and prevent disease
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.
Property Owner Print and Sign Date
Applicant acknowledges that the completeness of the application isconditional upon such further
niandatory and addii'ronal tests and rdports as may.be required by the local health deoartment to be
mã¿e andÎurnished by the applicant or by the locál health department for purpose of the evaluation of
the application; and ttie issuárice of the pêrmit is su.bject to such terms and conditions as deemed
neceés'ary to iniure compliance with rulés and regulations made,.information and.reports submitted
herewith'and required tò be submitted by the apþlìcant 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'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.
OFFICIAT USE ONLY ø
Special Conditions:ú
c5Fees Paid:4¡oóTotal Fees:
4 tr4.'ëffi".*
lssue Date:Balance Due:
ø ó.Ø
OWTS Permit
6tsP!i--7-gß
Building Permit
ß11{V-7R5Ð.
Garfield County Public Health Department:
Signed Approval
T
Date
11/10/2022
11/10/2022
Electric OtherPropaneType of Heat Natural Gas
PROJECT DETAITS CONTINUED
Septic:Community
Driveway
Permit:
NOTICE
Authoritv. This application for a Building Permit must be signed by the Owner of the property,described above,
oranauthorizedagent. lfthesignaturebelowisnotthatoftheOwner,aseparateletterofauthority,signedby
the Owner, must be provided with this Application.
Legal Access. A Building Permit cannot be issued without proof of legal and adequate access to the property for
purposes of inspections by the Building Division.
Other Permits. Multiple separate permits may be required: (1) State Electrical Permit, (2) County OWTS Permit,
(3) another permit required for use on the property identified above, e.g. State or County Highway/ Road Access
or a State Wastewater Discharge Permit.
Void Permit. A Building Permit becomes null and void if the work authorized is not commenced within 180 days
of the date of issuance and if work is suspended or abandoned for a period of 180 days after commencement.
CERTIFICAT¡ON
I hereby certify that I have read this Application and that the information contained above is true and correct. I
understand that the Building Division accepts the Application, along with the plans and specifications and other
data submitted by me or on my behalf (submittals), based upon my certification as to accuracy' Assuming
completeness of the submittals and approval of this Application, a Building Permit will be issued granting
permission to me, as Owner, to constructthe structure(s) and facilities detailed on the submittals reviewed by
the Building Division. ln consideration of the issuance of the Building Permit, I agree that I and my agents will
comply with provisions of any federal, state or local law regulating the work and the Garfield County Building
Code, OWTS regulations and applicable land use regulations (County Regulation(s)). I acknowledge that the
Building Permit may be suspended or revoked, upon notice from the County, if the location, construction or use
of the structure(s) and facility(ies), described above, are not in compliance with County Regulation(s) or any
other applicable law.
I hereby grant perm¡ssion to the Building Division to enter the property, described above, to inspect the work' I
further acknowledge that the issuance of the Building Permit does not prevent the Building Official from: (1)
requiring the correction of errors in the submittals, if any, discovered after issuance; or (2) stopping
construction or use of the structure(s) or facility(ies) if such is in violation of County Regulation(s) or any other
applicable law. Review of this Application, including submittals, and inspections of the work by the Building
Division do not constitute an acceptance of responsibility or liability by the County of errors, omissions or
discrepancies. As the Owner, I acknowledge that responsibility for compliance with federal, state and local laws
and County Regulations rest with me and my authorized agents, including without limitation my architect
andl or builder
I hereby acknowledge I have read and understand the Notice and Certification above, as well as, have
which is correct and accurate to the best of my knowledge.
"ì-
Prope
Permit #:
JrOFFICIAL USE ONLY o0
Special Conditionsl ,
tåiil¡itö6"'Misc. Fees:Plan Check Fee:Permit FeeAdjusted Valuation
5l;1fr-7Æ3OWTS No:
ß,r mF-?45?
BP No:Fees Paid:
fucn.@
Balance Due:Total Fees:
,w,Const. Type-TÐOOCC Group:T{oSetbacks:
BUILDING / PTANNING DIVISION :
Signed Approval Date