HomeMy WebLinkAboutApplication-PendingGarfield County
195 W. 14`h Street Public Health 2014 Blake Avenue
Rifle, CO 81650 Glenwood Springs, CO 81601
(970)625-5200 (970)945-6614
OWTS PERMIT APPLICATION,
TYPE OF SYSTEM CONSTRUCTION
111 New Installation
BUILDING USAGE TYPE
0 Dwelling
❑ Other Describe
INVOLVED PARTIES
❑ Transient Use
❑ Alteration Y ❑ Repair
❑ Comm./industrial ❑ Non -Domestic
Property owner:IRMW LLC Phone: 1970
Mailing Addre!
Email Address:
P O Box 1037 Carbondale CO 81623
Contra ctor: TAULY HO CONSTRUCTION
Mailing Address: RO. BoK 188 Rine, Co 61650
Email Address: IellQlallyhoconsi ucl on com
Engineer: sopris Engineering, Paul Rutledge & Yancy Nichol T
Mailing Address: 502 Main Street, Suile A3, Carbondale, CO 61623
970 16250208
Phone: 704 031.1
Email Address: pnrtledge@sop°sang Qom
PROJECT LOCATION AND DESCRIPTION
Job Address: 1058 County Rd 100, Carbondale, CO T
Assessor's Parcel Number:239335402001 Sub,irauwLLC-LrA`KAMINDRSMDM'10N% TLot Lot! 1A Blocs{
Building or Service Type: GARAGEISHOPIOFFICE #Bedrooms: NIA Garbage Disposal(Y/N)no
Distance to Nearest Community Sewer System:
Was an effort made to connect to the Community Sewer System: N/A
Potable Water Source Well ❑Spring ❑ Stream or [reek ❑ 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 far 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 know$, dge.
_ I
prop w r rint and Sig Date
OFFICIAL USE ONL
Special Conditions:
Per it Fee:
Total Fees:
fees Paid-
on,oa,o
Building Permit
OWTS Permit:
Issue Date:
Balance DD :
Garfield County Public Health Department:
Signed Approval
Date