HomeMy WebLinkAboutApplicationGarfield County
195 w. L4th street
Rifle, CO 81650
(970) 62s-s200
Public Health
OWTS PERMIT APPLICATION
20L4 Blake Avenue
Glenwood Springs, CO 81501
(970]'94s-66t4
E Vault and HaulX Major Repair E Minor Repair
TYPE OF SYSTEM CONSTRUCTION
E Alterationtr New lnstallation
BUILDINGVSAGE TYPE
tr Non-DomesticE Transient Use tr Comm./lndustrialX Dwelling
E Other Describe
INVOTVED PARTIES
Phone:Gonoer
Mailing Address 4453 Yates St, Denver, CO 80212
& Shelley rSUU t636-9UUU
l.comEmail Address: GO
r 970 t471-O913
Mailing Address:PO Box 1534, Eaqle, CO 81631
Email Address:l.com
t 9lO t 3U9-5259
129 Cains Lane, Carbondale, CO 81623
carla.ostberg@gmail.com
PROJECT TOCATION AND DESCRIPTION
Mailing Address:
Email Address:
Assessor,s parcer Numbe .2ggg'07 4-00-004uu. sec{ion: 7 Township: 7 Ranfle:a88 A TR ltfor 15
WasaneffortmadetoconnecttotheCommunitySewerSystem:
Job Address
Ga rbage Disposal(Y/NJ-4
Distance to Nearest Community Sewer System:more than 2 miles
Building or Service Residence
tr Spring E Stream or Creek E Cisterntr WellPotable Water Source
& Type ! Community Water System Name Caftle Crcek Water
Garfield County Public Health Department - working to promote health and prevent disease
CERTIFICATION
Applicant acknowledges that the completeness of the application is conditional .uPo.n such further
niandatory and addii'ronal tests and rdports as may be required by the local health d^rnartment to be
riA" rnO trrnished by the applicant oi by the locdl health department for purpose of the evaluation of
the application; and tlie issuirice of the pbrmit is su.bject to such terms and conditions as deemed
neceisary to iniure compliance with rulds and regulations made, information and.reports submitted
herewith'and required t6 be submitted by the applicant are or will be rep.res.ented 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 applied for herein. I
furiher understand that anyfalsifiiation or misrepresentation may result in the denialof 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
wetl as have provided the required information which is correct and accurate to the best of
my knowledge.
Shelley Conger 313112025
Property Owner Print and Sign Date
OFFICIAL USE ON
Special Conditions:
Fees Paid @ln6
Total Fees:(rfn.@Permit Fee:lr*f'tP
Balance Due:
1>)-
lssue Date:Building Permit OWTS Permit:
SFPf-qrbq
Garfield County Public Health Department:
Signed Approval Date
Garfield County Public Health Department - working to promote health and prevent disease
4/21/2025