HomeMy WebLinkAboutApplication-Pending195 W.141h Street
Rifle, CO 81650 Garfield County
(970) 625-5200
Public Health
OWTS PERMIT APPLICATION
TYPE OF SYSTEM CONSTRUCTION
❑ New Installation �� Major Repair
BUILDING USAGE TYPE
t[:3Dwelling
Other Describe
❑ Transient Use -
2014 Blake Avenue
Glenwood Springs, CO
81601
(970) 945-6614
❑ Minor Repair ❑ Alteration ❑Vault and Haul
❑Comm./Industrial f ❑ Non -Domestic
INVOLVED PARTIES
C loug4, 58 5- `-/�5'�1 fS93
Property Owner: ro 1 s r Phone: (970) S4 -1
Mailing Address:
Email Address: e r C. I
Contractor: �a ❑ fi5 I.a ri d co- i YN Phone: 70 `7 q
Mailing Address: 10 El Lb-c r� b r, v e- 5 i� ►�- Q / 1 "- 3
Email Address: W it d tC0015 5 20 via --I ( cz W, _ -
- - - - Phone: (q 7 D) � 5 0 - 0 5 7
Engineer: '^
Mailing Address: O L C 4 S (5a
Email Address: Lo-G%a �- • C ro n l� b� l o k .
PROJECT LOCATION AND DESCRIPTION
Project Address: ba
o71b
Assessor's Parcel Number: aM `6d i - USub. Lot Block
Building or Service Type: �? ill¢ #Bedrooms:_3Garbage Disposal(Y/N)�
Distance to Nearest Community Sewer System: 5 yyait,5�
i
Was an effort made to connect to the Community Sewer System: . , ► '@ r Vw" n
F Potable Water
Source & Type
❑ Well 1 El Spring El Stream or El Cistern
` Creek
Community Water System Name
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Garfield County Public Health Department —working to prornote 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
or 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.
3
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 Owner Print and Sign
3-1g- Flo
Date
Garfield County Public Health Department — working to promote health and prevent disease