HomeMy WebLinkAboutApplication - PENDING195 W. L4th Street
Rifle, CO 81650
(970) 62s-s200
Public Health
OWTS PERMIT APPLICATION
RECEIVED
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2014 Blake Avenue
Glenwood Springs, CO 81601
(970194s-66r4
E other Describe
Garfteld County
TYPE OF SYSTEM CONSTRUCTION
! Alteration n Vault and HaulX New lnstallation ! Major Repair fl Minor Repair
BUILDING USAGE WPE
! Comm./lndustrial Non-Domestic!K Dwelling I Transient Use
INVOTVEDPARTIES
Propertygwnsr; William D. Kenworthy and Catherine S. Kenworthy Phone
Email Address:wkenworthy@gmail.com
z( 704 1241-4394
223W Menomonee St., Chicago, lL 60614Mailing Ad
( 970 | 234-0112
Mailing Address 101'1 Heritage Dr., Carbondale, CO 81623
Email Address:zach@smithmb.com
Contractor:Smith Mountain Builders - Zach Smith
Was an effort made to connect to the Community Sewer System:
LOT 21 RANCH AT COULTER CREEK, GAR FIELD COUNTY. CO
(rrh .MNCH Ar couLrER CREEK PUQoL2l Slock _Assessor's Parcel Number:239107101021
rbage Disposal(V/ru)-Y4
E
Email Address:chris@mountaincross-eng.com
Distance to Nearest Community Sewer System:20 miles
Mailing Address 826 112 Grand Ave., Glenwood Springs, CO 81601
PROJECT TOCATION AND DESCRIPTION
Job Address:
No CSS in Coulter Creek subdivision
Building or Service Type Residential
Mountain n - Chris Hale one:( 970 ) 945-5558
E Cisternn wdt ! Spring E Stream or Crcek
X Community Water System Name Ranch at Coulter Creek HOA
Potable Water Source
& Type
GarJield County Public Health Department - working to promote healtlr and prevent disease
CERTIFICATION
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.
William D. Kenworthy Catherine Kenworthy
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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
neceis'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 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 permitgranted based upon said application and legalaction for perjury
as provided by law.
6130125
Property Owner Print and Date
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.sOFFICIAL USE ONLY ae)
Special Conditions:
ooTotal Fees:OcPermit Fee co
lssue Balance6 adBuilding Permit OWTS Permit:
Garfield County Public Health Department:
Signed Approval
t
Date
Garfield County Public Healtlr Department -'irvorking to pronrote heallh and prerrettt disease