HomeMy WebLinkAboutApplication-PendingGarfield County
Public lfeulth
195 w. t4th Street
Rifle, CO 81650
(e70) 62s-s200
2014 Blake Avenue
Glenwood Springs, CO 81601
(970) e4s-6514
OWTS PERM IT APPLICATION
TYPE OF SYSTEM CONSTRUCTION
X New lnstallation E Major Repair E Minor Repair E Alteration E Vault and Haul
BUILDING USAGE WPE
K Dwelling E Transient Use tl Comm./lndustrial tr Non-Domestic
tlOther Describe
INVOTVED PARTIES
Property 970 925.2855
Mailing Address
Email Address: chris@bendOnadams.com
contractor: Beek nuilding Gempany; Steve Bederefitonez( | 92A"471,1684
Mailing AddressT 80 Nottinoham Road: Avon. CO 81620
Emait Addresr. steve@beckbuilds.com
(\^^-i^ E^^:-^^-:^^. f.)^' 'l trl' '+1^,J^^Phone: ( g7g,Yg4,gg11wrf qqrr\ulrvvvv
MailingnddresS02 Main Street, Suite A-3; Carbondale, CO 81623
Email Addres* prutled ge@sopris.com
PROJECT rocAIlgN. 4N D DE9cRrqnON
Job Address:tfLuu owuEl,wcil.ttl r\cll lul I r\uclLr
Assesso/s Parcel R3000042 su6.Heathcote West Tra^h G-!toc1
Buirding or service rro"' Single-Family uBedrooms x6 Garbage Disposal(Y/N) Y
Distance to Nearest Community Sewer System:approx.10 miles
no
Was an effort made to connect to the Community Sewer System:
Potable Water Source
& Type
tr Well E Spring E Stream orCreek E Cistern
f; Community Water System Name vvYssLvvqf9r r \qr rvr r \yr rvqrv/,
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 additional tests 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 anyfalsification 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 of
my knowledge.
Lauren Mason M^-W l^*6126125
Property Owner Print and Sign Date
OFFICIAL USE ONLY I
Special Conditions:
Permit Fee:l"Ag Total Fees:l^m90 Fees Paid:Lffi oo
Buildine Permit
BOE, q,q;+OWTS Permit:
StrOh44rat,
lssue Date:Balance Due:+
Garfield County Public Health Department:
Signed Approval Date
Garfield County Public Health Department - working to promote health and prevent disease