HomeMy WebLinkAboutApplication-PendingPublic Heulth
195 W. L4b Street
Rifle, CO 81650
(970) 62s-s200
2014 Blake Avenue
Glenwood Springs, CO 81601
(s7o)945-6614
OWTS PERMITAPPUCATION
Gaffield County
WPE OF SYSTEM CONSTRUCTION
EI New lnstallation tr Alteration tr Repair
BUITDING USAGETYPE
E Dwelling I Transient Use tr Comm./lndustrial n Non-Domestic
El Other Describe
INVOLVED PARTIES
Property Kcith Bmd 970 37980n.2
Mailing AddfeSS' 147 GEnge Lans' catbondals co- 81623
Email AddfeS5; keith@teralinkstrudue.m
920
MailingAddress:
Email Address:
Sopds Enginering , Paul Rutledge & Yancy Nicfiol 'Bto )7()40311
Mailing AddfeSS: 502 Main Strsot, Suit€ A3, Calbondale, CO 81623
Email AddreSS: prutleds@$pd$ns.m
PROJECT LOCATION AND DESCRIPflON
JOb AddfeSS: fl)55 Cedar Drive,(Change Pending TBD), Carbondale, CO
ASSeSSOI,S ParCel NUmbg1.23e328411ln5 SUb. c@rrtonTmste. Loh B LOte Block tt
Building or Service RESIDENCE,#Bedrooms:3 Disposal(Y/N)* _
Distance to Nearest Community SewerSystem > I mile
Was an effort made to connect to the Community Sewer System:N/A
Potable Water Source
& Type
E Well
DWRpemit n#
E Spring E StreamorCreek E Cistern
E Communfi Water System Name
Garfield County Public Health Department - working to promote health and prevent disease
CERTIFICATION
Property Owner Print and Sign
Applicant acknowledges that the completeness of the application is conditional upon such further
n'iandatory 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 any falsification 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.
z,/tz,/Ps
Date
OFFICIAL UsE ONLY I
t a
Special Conditions:
Permh Fee:lD(nP Total Fees:(n(Y 9Q
Fees Paid:@Ir{)n
Buildins Permit
P,I,I\AV-qnl
OWTS Permit:
*pTQ?9A
lssue Date:aaunc:K
Garfield County Public Health Department:
Signed Approval Date
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