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2014 Blake Avenue
Glenwood Springs, CO 81"601
(970) 94s-6614
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195 W. 14th Street
Rifle, CO 81650
(e70) 62s-s200
OWTS PERM IT APPLICATION
Gurfteld Coun$
TYPE OF SYSTEM CONSTRUCTION
tr New lnstallation E lvtalor Repair E Minor Repair E Alteration E Vault and Haul
BUILDING USAGE TYPE
tr Dwelling E Transient Use X Comm./lndustrial tr Non-Domestic
E Other Describe
INVOLVED PARTIES
Property Owner: Phone : ( azol 24F'-oF'1n
Mailing Address 445 West Gunnison Avenue, STE22l Grand Junction co 81501
Email Address: csheata@usbr.qov
Wiseland Construction & Excavation ne: ( 970) 730 o74
Mailing Address:
Email Address:
PO Box 974, Palisade, CO 81526
alextOwiselandoi.com
Eric Blake e: ( 97Ol640-2A07
Mailing Address:
Email Address:
711 lndependent Ave.,Grand Junction, CO 81505
eric. blaketOstate.co. us
PROJECT LOCATION AND DESCRIPTION
Job Address: 5775 Co Hwv 325. Rifle. CO 81650
Assessor's Parcel Numbet, 212707100092 sub.-Lot-Block-
Building or service Type' maintenance shop, campground, #Bedrooms:-[-Garbage Disposal(Y/N] N
D i sta n ce to N e a re st co]n'$til?tit3t!"rl,e r syste m 7.5 miles
Was an effort made to connect to the Community Sewer System:No, not feasible
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
Applicant acknowledges that the completeness of the application is conditional upon such further
mandatory and additionaltests 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 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 anyfalsification 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
well as have provided the required information which is correct and accurate to the best of
my knowledge.
C-,r- S6aat:a s/19/202s
Property Owner Print and Sign Date
OFFICIAL USE ONtY
Special Conditions:
Total Fees:Fees Paid:Permit Fee:
-e,_
Building Permit
A+<
lssue Date:Balance Due:-a-
Garfield County Public Health Department:
Signed Approval Date
GarJield County Public Health Department - working to promote health and prevent disease