HomeMy WebLinkAboutApplication-Pending195 W. 14th Street Garfield Faun
Rifle, CO 81650 LU n•
r HV
(970) 625-5200
OWTS PERMIT APPLICATION
TYPE OF SYSTEM CONSTRUCTION
❑ New ❑ Major Repair ❑ Minor Repair Alteration
Installation
BUILDING USAGE TYPE
C Dwelling
❑ Other Describe
INVOLVED PARTIES
❑ Transient Use ❑ Comm./Industrial
2014 Blake Avenue
Springs, CO 81601
:ff o) 945-6614
GAkFIELG COUNTY
COMMUNiry I)EVELOPMENT
❑ Vault and Haul
❑ Non -Domestic
Property Owner: 7 lcalevs Phone: I D - dL -
Mailing Address: 7-35Q C20 OOAO,tsi�Le CO g?64, E3
Email Address:
Co
ntractor: -Phone:
iMailing Address: `�� {�vJn�� _ LC]L7 is rb c►tisj�- c3 S i f�Z�
Email Address: -74e �s7�' Id ��Srl e4
Engineer: Phone:
i Mailing Address: I Zq CO- n S L-44.. t"ba1 C C0 , iS t w Z.3 _
Email Address: 6,,,, Lo • C] S 4- l - CO
PROJECT LOCATION AND DESCRIPTION
Project Address: zys z. C too C a r to a r. cS�� 5s R � z
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Assessor's Parcel Number:Z3 1 l Sub.-1 i one- Po ,4 Lot Block
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Building or Service Type: ktf>"8-t"4- w` #Bedrooms: Garbage Disposal(YOIL
Distance to Nearest Community Sewer System: A L /
Was an effort made to connect to the Community Sewer System: /)O
Potable Water Well ❑ Spring ❑ Stream or Creek ❑ Cistern
Source & 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
he local health department for purpose of the evaluation of the application; and
he 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
ill be represented to be true and correct to the best of my knowledge and belief
nd are designed to be relied on by the local department of health in evaluating
he same for purposes of issuing the permit applied for herein. I further
understand that any falsification or misrepresentation may result in the denial of
he 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 Owner Print and Sign
y�z��Zo z4
Date
FOFFICIAL USE ONLY '
Special Conditions:
Permit Fee:
JM 00
Total Fees:
o a
Fees Paid:
Building Permit
OWTS Permit:
ILI
Issue Date:
Balance Due:
Garfield County Public Health Department:
Signed Approval Date
Garfield County Public Health Department — working to promote health a^A=-