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HomeMy WebLinkAboutApplication-PendingDocusign Envelope ID: BE97C9E9-77F3-4D3A-B401-ABE2D79D5F80 195 W. 14t" Street Rifle, CO 81650 (970) 625-5200 Garfield �Count?enwi r r OWTS PERMIT APPLICATION TYPE OF SYSTEM CONSTRUCTION ❑ New El Major Repair ❑ Minor Repair ® Alteration Installation ❑ Non -Domestic BUILDING USAGE TYPE ® Dwelling Li caner uescriDe INVOLVED PARTIES ❑ Transient Use ❑ Comm./Industrial 2014 Blake Avenue Springs, CO 81601 (970) 945-6614 ❑ Vault and Haul Property Owner: JACQUELINE DALY & LAWRENCE SWIFT Phone: ( 970 )309-4775 Mailing Address: 318 LIONS RIDGE RD, CARBONDALE, CO 81623 Email Address: JACKIEDALYREALTY GMAIL.COM Contractor: Mailing Address: Email Address: SMACMILLAN@GMAIL.COM ( 303 ) 981-2772 Engineer: JORDAN KEHOE Phone: ( 303 )591-3878 Mailing Address: 592 HWY 133, CARBONDALE, CO 81623 Email Address: JORDANK@RFENG.BIZ PROJECT LOCATION AND DESCRIPTION Project Address: 318 LI 81623 Assessor's Parcel Number:239130401008 sub. LIONS RIDGE EST. Lot 8 Block Building or Service Type: RESIDENTIAL #Bedrooms: 5 Garbage Disposal(Y/N) Y Distance to Nearest Community Sewer System: 1000'+ Was an effort made to connect to the Community Sewer System: No Potable Water ® Well ❑ Spring ❑ Stream or Creek I ❑ Cistern Source & Type ❑ Community Water System Name LI N`S R QC3 E E T NITY WEI Garfield County Public Health Department — working to promote health and prevent disease Docusign Envelope ID: BE97C9E9-77F3-4D3A-B401-ABE2D79D5F80 CERTIFICATION Applicant acknowledges that the completeness of the application is conditional upon such further mandatory and additional tests and reports as may be required Iby 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 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 knowiLrez ocuSigned by: �"MWA,, Va�'1 Property Owner Print and Sign 3/3/2026 Date OFFICIAL USE ONLY 'A Special Conditions: Per it Fee: ^� -/ Total Fee FeePaid: co ,cc ilding Permit OWTS Permit: Issue Date: Balance ue: Garfield County Public Health Department: Signed Approval Date Garfield County Public Health Department — working to promote health and prevent disease