HomeMy WebLinkAboutApplication-Pending195 W. 141h Street 2014 Blake Avenue
Rifle, CO 81650 Garfield
�0��� Glenwood Springs, CO
(970) 625-5200 �j L 81601
` H G E I V E t_) Public Health (970) 945-6614
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,., I ITY0 C;0 U T.'WWTS PERMIT APPLICATION
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TYPE OF SYSTEM CONSTRUCTION
New Installation ❑ Major Repair ❑ Minor Repair ❑Alteration ❑ Vault and Haul
BUILDING USAGE TYPE
EDwelling ❑ Transient Use ❑ Comm./industrial ❑ Non -Domestic
❑ Other Describe
INVOLVED PARTIES
Property Owner: MSR Lot 29: GLEN & KATHY MOORE Phone: ( 972)877-1779
Mailing Address: P.O. BOX 903. McKINNEY, TX 75070
Email Address: gmoore@xs-construction.com
Contractor: TBD Phone: 1
Mailing Address:
Email Address:
Engineer: MOUNTAIN CROSS ENGINEERING INC. Phone: ( 970)945-5544
Mailing AddreSS: 826 1/2 GRAND AVENUE GLENWOOD SPRINGS, CO 81601
Email Address: Chris@mountaincross-eng.com
PROJECT LOCATION AND DESCRIPTION
Project Address: TBD South Marsh Lane, CO 81601 (Lot - 29 Mountain Springs Ranch)
Assessor's Parcel Number: 218529200055 Sub. Mountain Springs Ranch Lot 29 Block
Building or Service Type: ROAD ACCESS #Bedrooms: 3 Garbage Disposal(Y/N)_
Distance to Nearest Community Sewer System: N/A
Was an effort made to connect to the Community Sewer System: NONE AVAILABLE
Potable Water ■ Well ❑ Spring ❑ Stream or ❑ Cistern
Source & Type Creek
❑ 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
Ibelief 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 reclu. ed for which is correct and accurate to the best of
my knowledge.
04/14/2026
Property Owner Print and Sign Date
OFFICIAL USE ONLY �Lba , C-G
Special Conditions:
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Permit Fee: (_Coo
Total Fees: (�,,,70 .cO
Fees Paid:
Building Per i e�
OWTS Per I
Issue Date:
Balance Due: �—
Garfield County Public Health Department:
Signed Approval Date
Garfield County Public Health Department — working to promote health and prevent disease