HomeMy WebLinkAboutApplicationGarJield County
195 W. 14th street
Rifle, CO 81650
(e70) 62s-s200
Public Heslth
OWTS PERM IT APPLICATION
2014 Blake Avenue
Glenwood Springs, CO 81501
(970) s4s-6614
TYPE OF SYSTEM CONSTRUCflON
E tt"* lnstallation
BUITDING USAGE TYPE
tr Dwelling E Transient Use
D Other Describe
tr Alteration
i n Comm./lndustrial
I tr Repair
tr Non-Domestic
INVOLVED PABTIES
Property BROADHURST, CHRISTOPHER J & TAMARA MARIE (s70 l
MdlingAdd 1420 County Rd 107, Carbondals, CO 81623
Email Address:
TALLY HO CONSTRUCTION ( s7o ) 625 0206
Mailing Address:
Email Address:lofi@tallyhrunslrctlon.@m
Englneer;Sopri6 Engineering, Paul Rulledss & Yancy Nlchol Phone:l<no l 704 031 I
Mailing Address:502 Main Slmt, SuitE 43, ca6ondals, CO 81023
Emall AddfeSS: prutlodge@Bopds€ng.mm
PROIECT TOCATION AND DESCf,IPTION
Job Address:1420 Counly Rd 107, Crrbond8le, CO
ASSeSSOI's Parcel NUmbef:!]]L1_108910 _ SUb. tod6zrdn!'p:?n44.:o01RrNN1,ew LOt_glOCk _
Euilding or Service Type:BARAGE/sHoPE R€sidsnlialADu ilBedrooms:2 Garbage Disposal(Y/Nl no
Distance to Nearest Community SewerSystem . >1mile
Was an effort made to connect to the Community Sewer System;N/A
Potable
r &Type
WaterSource E Wetl tr Spring I tr StreamorCreek
M@dft{* |
El cistern
E Community Water System Name
Applicant acknowledges that the completeness of the application is conditional upon such further
mandatory-and additionaltcsts and reports as may be reluired by the local heolth department to be
made and furnished by the applicant o; by the locil health depariment for purpose of the evaluation of
the application; and the issuance of the permit is subject to srich terms and'conditions as deemed
neces$ary 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 td 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 apptieU for herein. I
further understand that any falsifiiation or misrepresentation may resuli in the d'ehial of the
application.or revocation of any permit granted based upon said application and legal action for perjury
as provided by law.
CERTIFTANOiI
I hereby acknowledge that I have read and understand the Notice and Certification above as
well as have provided the requlred lnformation which is correct and accurate to the best of
my knowledge.
Property Owner Print and Slgn Date
OFFICIAL USE
t
Speclal Conditions:
Permit Fee:
f nOO .OA ^?"Bo.c)c2 Fees Paid:(rc OO
OWTS Permitr -3Ept-qA3a lssue Date:Balance Due:-€r-
Garfleld County Public Health Department:
Signed Approval Dete
5/9/2025