HomeMy WebLinkAboutApplicationGurfield County
Public Health
195 W. 14th street
Rifle, CO 81650
(e7o) 62s-s2oo
2014 Blake Avenue
Glenwood Springs, CO 81601
(97o) s4s-66L4
OWTS PERM IT APPLICATION
TYPE OF SYSTEM CONTTRUCTION
tr New lnstallation M walor Repair E Minor Repair E Alteration ! Vault and Haul
BI/ILDING USAGE WPE
M Dwelling n Transient Use tr Comm./lndustrial n Non-Domestic
E Other Describe
INVOLVED PARTIES
Property Owner: Phone:( 41$260-4165
Mailing Address:11 '18 Heritag e Dr Carbondale, CO 81623
Email Address Todd@unionprope rtycapital.com
The Home Grou lnc.r 970)319-7378
Mailing Address 183 N 12th St Carbondale, CO 81623
Email Address jackv@thehomegroupi nc.com
Engineer:Carla Ostberq Pho ne: { 970)30
Mailing Address 129 Cains Lane Carbondale, CO 81623
Email Address:carla.ostberg@gmail.com
PROJECT LOCATION AND DESCRIPTION
lob Address:Cou Road 109 1
Assessor's Parcel Nu 23932831 8001 m ock
Building or Service Type: Single Family Home #Bedrooms:-1l-Garbage Disposal(Y/N) Y
Distance to Nearest Community Sewer System 2-3 Miles over bridge
Was an effort made to connect to the Community Sewer System Existing Septic
Potable Water Source
& Type
V wett ! Spring E Stream or Creek E Cistern
E Community Water System Name
Garfield County Public Health Department - working to promote health and prevent disease
X 4 ERW 8/1/24
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 subjectto 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 or will 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 is correct and accurate to the best of
my knowledge.
7t26/24
Property Owner Print and Sign Date
Special Conditions:
Permit Fee:-g Total r.ur$_
Building Permit
BU?I-,X(ar
OWTS Permit:
SEgl- Rkr-l-
lssue Date:Balance Due:tu
Garfield County Public Health Department:
Signed Approval Date
Garfield County Public Health Department- working to promote health and prevent disease
08/01/2024
08/01/2024