HomeMy WebLinkAboutApplication-PendingGarfield County
195 W. 141h Street Public Health 2014 Blake Avenue
Rifle, CO 81650 Glenwood Springs, CO 81601
(970) 625-5200 (970) 945-6614
DINTS PERMIT APPLICATION
TYPE OF SYSTEM CONSTRUCTION
❑ New Installation 1 ❑ Major Repair ❑Minor Repair Alteration ❑ Vault and Haul
BUILDING USAGE TYPE
V1 Dwelling ❑ Transient Use ❑ Comm./Industrial ElNon-Domestic
❑ Other Describe
INVOLVED PARTIES
Property Owner: loky% 6%yl d V_4-1 Sin (% :i_4rn oLyti Phone: (0110 ) 418 "1- dale 1
Mailing Address: 4533 C0jir1-tc ns)ed Z3_1 5i14,60 eI[45�
Email Address: r t� 1r1� iTYloli l . (�,r►n
Contractor: IokyS $4rn 4Ln C6wner ] Phone: (9'l u ) 3-701- Ig oa
Mailing Address: 4r3 3 rA)L/ n-+g f20 -: Io Si 14, Co %I Lvs?�
Email Address: Iov► aL 1Uy_f1ec..-I-ri c. (.e),vA
Engineer: Phone: (r4-1 b ) 3 La (r - Ssl,, R 0
Mailing Address: a541p NiU(7v1Y1 d q
Email Address: 5Abd1 D M . e1ng,,rleer Q 4 rn 06 1 • La rv,
PROJECT LOCATION AND DESCRIPTION
_
Job Address: S3 3 Losm±9 Q �o�l- �3"1 S i 1.1, C D L; L(o 5d1.
rrct $ec+,ur,:3V �
Assessor's Parcel Number: 2.1ll';Ip'a.00OloSub. AY1k1e5 ()nMwrd Lot 9 Block'Cbwns`^kV
wyc: �a
Building or Service Type: Cyr d-Cyice #Bedrooms: Garbage Disposal(Y/N) N
Distance to Nearest Community Sewer System:
Was an effort made to connect to the Community Sewer System:
Potable Water Source
Well TO
Spring I El StreamorCreek
❑ Cistern
& Type
❑ 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 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
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 knowledge.
IL7r1S�ir �yrnwh San 9YVKCkV\ 3 S
Property Owner Print and Sign
Date
OFFICIAL USE ONLY
t .
Special Conditions:
P rmit Fee `
otal Fees:
Fee; Paid:
Building Permit
OWTS Permit:
Issue Date:
Balance Due:
Garfield County Public Health Department:
Signed Approval Date
Garfield County Public Health Department — working to promote health and prevent disease