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195 W. L4th Street
Rifle, CO 81650
(970) 62s-s200
Public Health
OWTS PERM IT APPLICATION
2014 Blake Avenue
Glenwood Springs, CO 81601
(970194s-661,4
Guffield Coun$
EI Alterationtr New lnstallation E Major Repair
BUILDING USAGETYPE
tr Dwelling E Transient Use E Comm./lndustrial tr Non-Domestic
E other Describe
WPE OF SYSTEM CONSTRUCTION
E Minor Re tr
i INVOLVED PARTIES
Engineer: Phone : ( 970 l7O4-O3tI
Mailing Address: 502 Main Street, Suite A-3
Email Address yn ichol@ sop rise ng.com
PROJECT LOCATION AND DESCRIPTION
E Vault and Haul
Property Owner Ucc-ts LLLP Phone
Mailing Address' 132 Park Ave Basalt, CO 81621
Email Address:ch ris@ ruddconstruction. com
:{ 970 )309-0123
Email Address: chris@ruddconstruction.com
Mailing Address: 132 Park Ave Basalt, CO 8162I
E Stream or Creek E CisternB Well tr SpringPotable Water Source
& Type D Community Water System Name
Job Address: 0062 Cou Road 113 Carbonda co 81621
Assessor's Parcel Number
Building or Service Type:warehouse #Bedrooms: 0 Garbage Disposal(Y/N) n
Distance to Nearest Community Sewer System:
WasaneffortmadetoconnecttotheCommunitySewerSystem:
Gar-field County Public Health Depadment - working to promote health and prevent disease
CERTIFICATION
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 bythe applicant or bythe local health department for purpose of the evaluation of
the application; and the issuance of the permit is subject to such terms and conditions as deemed
necessaryto 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 anyfalsification or misrepresentation may result in the denialof the
application or revocation of any permitgranted based upon said application and legalaction 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.
Property Owner Print and Sign Date
OFFICIAL USE ONLY
Special Conditions:
Permit Fee:
'lco .oo TotalJees:&o cro Fees Paid:Joo oo
Buildine Permit
&tca.qnus
OWTS Permit:
SEFr.tRQta
lssue Date:Balance Due#
Garfield County Public Health Department
Signed Approval Date
Garfield County Public Health Department - working to promote health and prevent disease