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WELD
COUNTY HEALTH DEPARTF
1516 Hospital Road
Greeley, Colorado
PH. 353-0540 3
Application for permit to install, construct, an Individ
i
Owner /J 2j241ek !'e tyre,.Ce-mi
Directions to site: Hwy Rd.
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Address 2,20/-i,-;.? i.„-,p t 7 Phone
N mi, E mi, S mi, W mi
Legal Description: Pin-Su/.(2,7'4/ Sec. / O' ,T /,N, R , 'W, Sub. Lot4 B1k
I General Information
No. Bedrooms ,.,2 , No. Persons
No. Baths . _2_ /La..
Size of Lot / 41..„.,
H2O supply (If well give depth) /,///,Q,
New Home,. --Mobile Home Modular_ Add'n
Type of sewage �disposal requested:
Septic tankt/ rrivy Other
Basement Plumbing _
^r
Perc rate (avg. of 3)
Soil Type
H2O Table Depth .7
Lot Grade_
Engineer Design Yes s-- No
If YES -reason:
Comments:
This is to certify that the system is NOT within 400 ft. of a public sewer.'<%' ,-
Septic Tank
Other
Special Instructions
Installation instructions: (Minimum Requirements)
756
Gals.
Absorption Trenches
or
Seepage Bed 3749 Sq. Ft.
X90
Sq. Ft.
This system will be constructed and installed in accordance with the above specifications
and regulations regarding individual sewage disposal systems in Weld County, Colorado.
This permit shall expire at the same time as the building permit, or, if no building permit
is issued, the permit shall expire 120 days after its issuance if construction has not
been commenced.
Date:
13 79-2 '
Owner:
"
Applicant:LA/ ,7�6cvsnA ..
The plans and specifications as shown are approved pending payment ofe.permit fee.
Date: /a -al- 7P
Sanitarian:
The above system inspected and found to comply with plan and description.
Date:
Systems Contractor:
Engineer Review:
(Date)
c -I-7.7_
Sanitarian; / �j
Pormll Fee: $ '$`O.O0
Received by: (
L L�
Date:
(Signature)
•
1000 cr«,P_ d a -►1
NORTi4
\aLIU
COLP.TY _
WATER
r.c
CUT -rift::: :..._.... _.
Total A--nount Due
NORTH WELD COUNTY WATER DISTRICT
P O BOX 56
32R25 CR 39
LUCERNE, COLORADO 806,16
1 AX Er )01 395-09' 7 I -MAIL w:Uprr enwcwd org
r 11,:%n ImPE
Prey. Read
ALIOUIlt Dut Dy umur>e13
01.50
AIAOUNI PAID
.\ns payment teL-d yed utter the 10th of the month may
not show on this billing.
1'Icl.c note than all accounts are due by the IOth of the
month.
Return this slob with your payment
Thank you.
BILLING PFP.GD
02/22/2013 - 03/25/2013
Carr. Read Usage Unit Type Amount
333
6 kgal
Effective November 2012 Billing:
Plant Investment Surcharge:$3.95 per Kgal Tier 1 S1.95 per Kgal Tier 2
Water Allocation Surcharge: $1.00 per Kgal
Water Rate Increase Effective January 2013 Billing:
0-10 Kgal of usage = $30.50 Over 10 Kgal $3.05 per Kgal
61.00
p 30.50
30.50
91.50
30
I I' l
I I II .
•.I �I
;l
i s 1I1
y ,v
Aug
Sep
Oa Nov Dec Jan Feb Mar
Water Class
70 & of 1.000 Acre Foot
Transferred Water
Allocation Adjustment
Less YTD Usage
Remaining Water Allocation
Plant Investment Class
70 % of 1.000 Acre Foot
Less YTD Usage
Remaining PI Allocation
P (KGal)
228
0
0
19
209
228
19
209
NORTH WELD COUNTY WATER DISTRICT • PO e0% se.32e25CR 39, LUCERNE, CO80646 • PH: 970-356-3020 • FAX: 970-395-0997 • E-MAIL: weler@nwcwd org
Board of Directors Charles Ad-iiger, Gene Sure. Robes Ambreda. Todd Dean, Gary Simpson Manager. Don Possell
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