HomeMy WebLinkAboutApplication-PendingFAWjL- �e h. Garfield County
195 W.14"' 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 CONSTRUMON
M New Installation ❑ Alteration ❑ Repair
BUILDING USAGE TYPE
❑ DwelEirtg ❑Transient Use ® Comm./In ustrialj ❑ Non -Domestic i
❑ Other Describe
INVOLVED PARTIES -
Property Owner: Leonard Olfm: Big Lennys Storage,Ritte LLC Phone: 9981016 or 806 4153
MailingAddress: 5458 mount vow on ParkwayAtienta. GA M27. PO. l3ox 2834 Ale;,C0 81623
Email Address: Angela Newman: newmanangsia2015@gmell com Leonard:Otim: bigiennyotim@gmaslsram�
CaFftrar tor: Myrt Serra 5M ConslrucSIon. _LLC Phone: j e70 12082754
Mailing Address:
Email Address: 5mcG=Lncfgmai[-cem
Engineer: soPrb t • p+L� Ru0w9v a'Ymmey Kkw Phone:-(970 704 03 t 1
Mailing Address: soz Main saver, suns A3. C hmdak. Co 81623
Email Address: p,w.a�•
PRCUECT LOCATION AND.DESC01MdN.
Job Address: 184 Gas Court. Rifle. CO.81 M _
Assessor's Parcel Number: 2177182010M Sub.west Ripe Industrial Park Lot.4Lot4 Block
Building or Service Type:c0mmerdai 00drooms:n/a Garbage Disposal(Y/N)nla
Distance to Nearest Community Sewer System: ' m1w
Was an effort made to connect to the Community Sewer System; NIA
Potable Water Source
& Type
Well
DWR parmft
❑Spring
❑ Stream or Creek
❑Cistern
M Community Water System Name cAty of We
Garfield County Public Health Department — working to promote health and prevent disease
■
TIt=1CAFiON
Applicant acknowledges that the completeness of the application is conditional upon such further
mandatgQL and additional tests and reports as may beulred by the focal health department to be
made an 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.
Property ow r kr t and Sign
Special Conditions: -
Permit Fee:
0 TotplFees:
Building Permit oWTS permit: Issue Date:
i
- _y�,2
l C•I�
Garfield County Public Health Department: _
Signed Approval
Date
Fees Paid.-
Qd
Balance Due:
Date
1 pdatcd Dec :013