HomeMy WebLinkAboutAmended Application-PendingGurfield County
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Public Health
195 w. 14th Street
Rifle, CO 81650
(970) 62s-s200
2014 Blake Avenue
Glenwood Springs, CO 81601
(9701 94s-66r4
OWTS PERM IT APPLICATION
TYPE OF SYSTEM CONSTRUCTION
El ruew lnstallation tr Alteration tr Repair
BUITDING USAGE TYPE
E Dwelling E Transient Use tr Comm./lndustrial tr Non-Domestic
E other Describe
INVOTVED PARTIES
Property Qq;ps1; ccc-B LLLP Phonel 970 379-9263
Mailing Addfg5S' 0132 Park Avenue Basalt, Colorado 81621 '
Email Address:eric@rudd@nstruction,mm
Contractor: Phone: (_)
Mailing Address:
EmailAddress:
Sopris Engineering , Paul Rutledge & Yancy Nichol Phone:btn )704 0311
Mailing Address 502 Main Street, Suite A3, Carbondale, CO 81623
Email AddreSS: prutledse@sopriseng.com
PROJECT TOCATION AND DESCRIPTION
Job Address 62 County Road 113,Carbondale, CO 81623
Assessor's Parcel Number 23931 8100358 M&B Lot Block
Building or Service Type:commerciar #Bedrooms:11-Garbage Disposal(Y/N)no
Distance to Nearest Community Sewer System:> 2 mile
Was an effort made to connect to the Community Sewer System:N/A
Potable Water Source
& Type
E well tr Spring E Stream or Creek E Cistern
E Community Water System Name
Garfield County Public Health Department - working to promote health and prevent disease
CERTIFICATION
my
Appliuarrl. ackrruwledges Llral. Lhe conrpletelress of tlre applicatiulr is culrdil,iolral upurr suclr fur Llter
mandatory and additional tests and reports as may be required by the local health department to be
made and turnished by the applicant or by the local health department tor purpose of the evaluation ot
the application; and the issuance of the permit is subject to 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 ofn"'YIu
3120125
Property Owner Print and Sign Date
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Special Conditions:
Permit Fee
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Total Fees:Fees Paid oo(*l( rcl
Building Permit
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OWTSJermit:3Hm4d$to lssue Date:Balance Due:
Garfield County Public Health Department
Signed Approval Date
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