HomeMy WebLinkAbout20131509.tiffForm No. OFFICE OF THE STATE
GWS-25^ COLORADO DIVISION
818 Centennial Bldg., 1313 Sherman
(303) 866-3581
APPLICANT
ENGINEER
OF WATER RESOURCES
St., Denver, Colorado 80203
LIC
WELL PERMIT NUMBER 247857 - -
DIV. 1 WD2 DES. BASIN MD
FOREST E & JACQUELINE K MCCONNELL
BOX 748
FREDERICK, CO 80530-
(303) 833-2647
PERMIT TO CONSTRUCT A WELL
APPROVED WELL LOCATION
WELD COUNTY
NW 114 SW 1/4 Section 18
Township 2 N Range 67 W Sixth P.M.
DISTANCES FROM SECTION LINES
2170 Ft. from South Section Line
350 Ft. from West Section Line
UTM COORDINATES
Northing: Easting:
1)
2)
3)
4)
5)
6)
7)
8)
9)
ISSUANCE OF
This well shall be used in such a way as
does not assure the applicant that no injury
water right from seeking relief in a civil
The construction of this well shall be in
of a variance has been granted by the
Contractors in accordance with Rule 18.
Approved pursuant to CRS 37-92-602(3)(b)(I)
2.52 -acre parcel known as lot A of Recorded
attached Exhibit A.
The use of ground water from this well
watering of four (4) large non-commercial
gardens and lawns.
The total depth of the well shall not exceed
minimum, plain casing shall be installed
ten feet into the bedrock formation to prevent
The depth to the top of the Laramie -Fox
zones immediately above the aquifer, plain
shale that overlies the Laramie sand portion
The maximum pumping rate of this well
The annual withdrawal of ground water
The return flow from the use of this well
less than 2% of the total amount of water
NOTE: The ability of this well to withdraw
the 100 years upon which the amount of
NOTE: To ensure a maximum productive
interval of the approved zone or aquifer
NOTICE: This permit has been approved
the attached exhibit A and for the amount
the right to appeal the issuance of this
issuance, pursuant to the State Administrative
THIS PERMIT DOES NOT CONFER A WATER RIGHT
CONDITIONS OF APPROVAL
to cause no material injury to existing water rights. The issuance of this permit
will occur to another vested water right or preclude another owner of a vested
court action.
compliance with the Water Well Construction Rules 2 CCR 402-2, unless approval
State Board of Examiners of Water Well Construction and Pump Installation
and policy of the State Engineer under the following conditions, for a
Exemption no.1311-18-3 RE -3463, more particularly described on the
is limited to ordinary household purposes inside one (1) single family dwelling, the
domestic animals, and the irrigation of not more than 5,000 square feet of home
285 feet, which corresponds to the base of the Laramie -Fox Hills aquifer. At a
and grouted through all unconsolidated materials and shall extend a minimum of
production from other zones.
Hills aquifer is approximate. To ensure the exclusion of poor quality water from
casing and grout shall extend through the lowermost coal and/or carbonaceous
of the aquifer.
shall not exceed 15 GPM.
from this well shall not exceed 0.60 acre-feet.
must be through an individual waste water disposal system of the type so that not
withdrawn is returned to the same stream system in which the well is located.
its authorized amount of water from this non-renewable aquifer may be less than
water in the aquifer is allocated, due to anticipated water level declines.
life of this well, perforated casing should be set through the entire producing
indicated above.
for the location of the proposed well pursuant to the description of the parcel in
of water available underlying said parcel. You are hereby notified that you have
permit, by filing a written request with this office within sixty (60) days of the date of
Procedures Act. (See Section 24-4-104 through 106, C.R.S.)
��- c/ 03
APPROVED
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State Engineer By
No. 0504588 DATE ISSUED 02-24-2003 EXPIRATION DATE 02-24-2005
Colorado Division of Water Resources
1313 Sherman St. Rm. 821
Denver, CO 80203
(303) 866-3581
http://water state.co.us/default.htm
Application Receipt No
Applicant's Name
SUPPLEMENTAL INFORMATION FOR SMALL CAPACITY COMMERCIAL WELL PERMIT APPLICATIONS
(For Wells Located Within Designated Groundwater Basins)
Small capacity commercial well permit applications are evaluated pursuant to the provisions of CRS 37-90-105, which
allows for one well in one commercial business. Pending approval, the use of this proposed well for a commercial
business having another small capacity commercial well is prohibited. This supplemental information form is
necessary in order to determine whether your application qualifies within the provisions of this statute.
Please answer the following questions using type or black ink. If additional space is needed, identify the question number
on a separate sheet, then attach to this form. This form must be signed and dated below.
1. Name the type of business this proposed well will serve. C1t dCct t I [i Ric , LLC
2. Will you own and operate this proposed well and the commercial business L j S
• If not, please explain who will own and operate this well and the business served by this well?
3. Do you qualify as one commercial business as defined under CRS 37-90-105(1)(c)(II) (see below for referenced
statute). Lie(----)
4. Do you currently have a valid permit for any other small capacity commercial well inside any Designated Ground
Water Basin in Colorado?
NU
• If so, please provide the permit number(s) of any valid permit(s) you have.
I (we) have read the statement made herein, know the content thereof, and state that they are true to my (our) knowledge.
[Pursuant to section 24-4-104 (13)(a) C.R.S., the making of false statements herein constitutes perjury in the second
degree and is punishable as a Class 1 misdemeanor.]
Name/Title (print or type): - n
Signature:
CN
Date: i0013
G13
Under CRS 37-90-105 - Small Capacity Wells, paragraph (1)(c) (II) reads as follows:
To qualify as a "commercial business" under this paragraph (c), the business shall be:
(A) A business that will be operated by the well owner and that will have its own books, bank accounts, checking
accounts, and separate tax returns;
(B) A business that will use water solely on the land indicated in the permit for the well and for the purposes stated in
such permit;
(C) A business that will maintain its individual assets and will own or lease the property on which the well is to be located
or where the business is operated;
(D) A business that will have its own contractual agreements for operation of the business;
(E) A business that agrees not to transfer a permit issued under this paragraph (c) to another entity that also holds a
small capacity commercial well permit under this paragraph (c); and
(F) A business that agrees to notify any potential buyer that such buyer shall notify the state engineer of any change in
ownership of such business within sixty days after any such change in ownership.
GWS-58
06/2011
COLORADO DIVISION OF WATER RESOURCES
DEPARTMENT OF NATURAL RESOURCES
1313 SHERMAN ST., STE 821, DENVER, CO 80203
main. (303) 866-3581 ri:tp '%+Utei.stale co us
Form GWS-57 (10/2011)
Application Receipt No.
Applicant's Name:
fax (303) 866-3589 Online Requests: AskDWR
COMMERCIAL DRINKING AND SANITARY WELL WORKSHEET
Review instructions on reverse side prior to completing form. The form must be completed in black or blue ink or typed.
1. Name and Type of Business:
1 ►{1 Hs
k;L Ghdcare�
2. Is this application for a new well?
E Yes
i$ No 1f no, is this application for a change of use for an existing well?0Ri1-7ccrJ,7
,� Yes Permit Number of well (if applicable)
■ No For wells used for drinking and sanitary purposes prior to May 8, 1972, a field inspection of the well to
verify historical uses may be required. See form GWS-12 Registration of Existing Weil and
form GWS-12A Statement of Historical Use for further information.
3. Is the parcel the well is located on (or will be located on) within the boundaries of a water service area (water district,
municipality, water company, etc.) or is water available from another source (such as a well)?`t ' ` --1n �S s7
RI Yes If yes, indicate what this other source is
E No (name of water distncUsupplier, or well permit number)
4. Proposed type of disposal system
to be used:
Septic tank / absorption leach field
Central System (district name.)
O Vault (location sewage hauled to:)
■ Other (attach copy of engineering design)
5. Water Demand Calculations (for average factors for water demand see below)
Employees
Number of
Employees
X
Number of Gallons
per Employee per Day
X
Number of Days Employee
Works per Year
=
Gallons per Year
I
X
t
X
,i.�j0
=
3,--1C )
A
Customers
Number of
Customers per Day
X
Number of Gallons
per Customer
X
Number of Days Business
is Open per Year
=
Gallons per Year
11
X
1 D
X, t)
=
,Q?.( -goo
B
Other Uses (Note: No uses outside of the building would be permitted for this type of well.)
Type of Use
X
Gallons per Use per Day
X
Days per Year
=
Gallons per Year
X
X
=
C
Total amount of water required:
=
Gallons per Year
(A+B+C)
For wells used for commercial drinking and sanitary purposes on or after May 8, 1972, the total water demand cannot exceed
108,600 gallons (1/3 of an acre-foot) per year.
For wells used for commercial drinking and sanitary purposes prior to May 8, 1972, the total water demand cannot exceed 325,900
gallons (1 acre-foot) per year.
General Guidelines for Water Demand in Gallons per Day
Day Workers at Offices —15 gallons/person/day
Food Service Establishments (with toilet and kitchen wastes) — 10 gallons/patron/day
Churches (does not include food service) — 5 gallons/seat/day
Overnight Lodging — 50 gallons/customer/day
On -Site Proprietor of Overnight Lodging (i.e. on -site owner of a Bed & Breakfast) — 80 gallons/person/day
Additional water demand figures may be obtained from a private water consultant or from a technical reference on this subject.
COLORADO DIVISION OF WATER RESOURCES
DEPARTMENT OF NATURAL RESOURCES
1313 SHERMAN ST, RM 821, DENVER, CO 80203
Main: (303) 866-3581 Fax: (303) 866-2223 dwrperrnitsonline@state.co.us
GENERAL PURPOSE
Water Well Permit Application
Review Instructions on reverse side prior to completing form.
The form must be computer generated, typed or In black or blue ink.
1. Applicant Information
Name of applicant
•
Office Use Only
Form GWS-45 (04/2012)
Jermt v ,dggtAih _
Maibrig atldreu
� dereu Cu,, � . 13 Ttle
erg l E-mail Wine (Ming required)
lag at Slet6)M . Car
(clerk 4pplicable boxes)
Telephone a ( a code 6 number)
1 u-2i1G-211D
2. Type Of Application
6. Use Of Well (check applicable boxes)
Attach a detailed description of uses applied for.
❑ Industrial
o Municipal
0 Irrigation
Commercial
❑ Dewatering System
Cl Geothermal (production or reinjection)
❑ Other (describe):
El Construct new well
El Replace existing well
❑ Change source (aquifer)
El COGCC Well
❑ Use existing well
Er Change or increase use
❑ Reapplication (expired permit)
❑ Other:
7. Well Data (proposed)
Maximum pumping rate Annual amount to be withdrawn
IS
gpm
Total depth
cZn
feet
a(,O
Aqu net
l— tram(e.-- Vox
acre-feet
3. Refer ToL(if
�applicable)
Welpenmt#� rx
1 1 :75 7
Designated Basin Detammnadon a
Water Coon case a
Well name ors
4. Location Of Proposed Well
county WeAd
rGLltMIPaf 1/4 of tie 114
Section Township N or S Range E or W Pnnopal Menden
I S XI rl (,--� ❑ VI
Distance dwell from section lines (section lines are typically not property lines)
Ft. fromrNTS Ft. hone QW
For replacement wells only — distance and direction horn old well to new well
feet
Well location address (Include City. State. Zip)
61351) Wet . 12)
kin( \MAI (-, Co eeSbi-
OptionalOGPS well location information In UTM format You must check GPS unit for
required settings as follows:
direction
ElCheck if well address is same as in Item I
Fomtat must be UTM
r Zone 12 Orin Zone 13
Units must be Meters
Datum must be NAO83
Unit must be set to Mae north
Was GPS rant chedted for above? ❑ YES
Easting
Northing
Remember to set Datum to NAD83
8. Land On Which Ground Water Will Be Used
Legal Description of Land (may be provided os an attachment):
L. 01 A J- Qv_ kefVki)Aieria Nom. i31I-I2 3-
RE3 Runnyq Path tk SL vets} & ta(Fcd
c -C- Sc4 4, cvt t$`,'Taltvaslrit r L N e•(-Nr, Rant o1
hest- -u 'p.m,Ccutniof— We1e1,Stct of Colt
(If used for crop irrigation, attach a scaled map that shows irrigated area,)
A. at Acres - � B. Owner
Jenn kfe jLcsh
C. List any other wells or water rights used on this lend:
9. Proposed Well Driller License #(optional):
10. Sign or Entered Name Of Applicant(s) Or Authorized Agent
The making of false statements herein constitutes perjury in the second
degree, which is punishable as a class 1 misdemeanor pursuant to C.R.S.
24-4-104 (13)(a). I have read the statements herein, know the contents
thereof and state that they are true to m rLknowledge.
Sign or enter names) of person(s) submitting application
If agntitg print n tills V
X12�lln\t' Y JC1C kAIS\1
Office Use Only
USGS map name
Date (mmlddryyyy)
21luI 13
5. Parcel On Which Well Will Be Located
(PLEASE ATTACH A CURRENT DEED FOR THE SUBJECT PARCEL)
A. Legal Description (may be provided as an attachment):
- 1k tQ (-. by dQQ
No. ill --113.--3-12C";46, Poil1,O.x1 of -Nie-
SC %n Ncs4 Gtuadl-cr cc_ 5cc_KI n :RA%Askp
2 Nci4tkin, (ZAnf . 1,7 Wtsl- of- -khe (p p.m•, l' pnhjof
B. a of acres in parcel C. Owner
2.52 Jenn\cc.l! JnC,u�Sh
Will thi
s is be die only well on this parcel? ® YES NO (if no list otter watt
E. Slate Parcel IDS (optional)
I3I 11 g3000e.7
v kkt , Sira.k o� Col o: ado
DWR map no.
Surface des.
Receipt area only
AQUAMAP
WE
WR
CWCB
rOPO
MYLAR
SB5 DIV WD BA MD
Colorado Division of Water Resources
1313 Sherman St. Rm. 818
Denver, CO 80203
(303) 866-3581
http.//water state co.us/default.htm
Application Receipt No.
Applicants Name
COMMERCIAL SMALL CAPACITY WELL WATER USE BREAKDOWN WORKSHEET
(For Wells Located Within Designated Groundwater Basins)
Name and Type of
Business
in
-ThKis , Ch11dca{
1. Is this application for a new well?
Yes
X No If no, is this application for a change of use for an existing permitted �.sell? ?
Yes Permit Number of well (if applicable) 5
No For wells used prior to May 8, 1972 see form GWS-12 Registration of Existing Well for
further information.
2. Type of disposal system
Septic tank/absorption leach field
Central System (district name:)
Vault (location sewage hauled to: )
Other (attach copy of engineering design)
3. Water Demand Calculations (for average factors for water demand see below)
Employees
Number of Employees
X
Number of Gallons per
Employee per Day
X
Number of Days Employee
Works per Year
=
Gallons per Year
1
X
15
X
a.5D
=
3,-J15o
Customers
Number of
Customers per Day
X
Number of Gallons per
Customer
X
Number of Days Business
is Open per Year
=
Gallons per Year
11
X
l l_2
X
_
C)
=
.T7 co(.)
Outside
Square Feet of
Irrigated Landscape
X
Number of Gallons per
square foot per day
X
Number of Days landscape
is irrigated
=
Gallons per Year
__—
X
X
=
Other Uses - Provide breakdowns for all other substantial water usage (l e. veterinary clinic, green houses, etc.
Type of Use
X
Gallons per Use per
Day
X
Days per Year
)
Gallons per Year
X
X
B
C
D
Total amount of water required: 31, aS7,:7 gallons per year
(A+B+C+D)
14:71I ( L}t� acre -ft per year
(1 acre -ft = 325,851 gallons)
For all small capacity commercial wells:
1. The pumping rate shall not exceed 50 gallons per minute and may be further limited by Water Management District
Rules.
General Guidelines for Water Demand in Gallons per Day
Day Workers at Offices —15 gallons/person/day
Food Service Establishments (with toilet and kitchen wastes) — 10 gallons/patron/day
Churches (does not include food service) — 5 gallons/seat/day
Overnight Lodging — 50 gallons/customer/day
Landscape Irrigation — 45 gallons/1,000 square feet/day
On -Site Proprietor of Overnight Lodging (i.e. on -site owner of a Bed & Breakfast) — 80 gallons/person/day
Additional water demand figures may be obtained from a private water consultant or from a technical reference on this subject. GWS-61
03/03
Scanning Cover Sheet
for
Septic Permits
Permit #
Permit Type:
SP -0300245
Health / Residential / New
Situs Street Address 9350 CR 13
Situs City, State, Zip
Sec/Town/Range: 18 -02N -67W
Parcel # (12 digits)
Owner Full Name:
Owner Address:
Contact Name:
Contact Address:
131118300067-R2235703
MCCONNELL JACQUELINE
9350 CR 13
LONGMONT,CO 80504
LEON BACKHOE SERVICES
353 N ASH ST
KEENESBURG,CO,80643
Application Status: Finaled
Application Date: 06/26/2003
Owner Phone #: 303.833.2647
Contact Phone# 303.732.4590
Information above has been Verified in Accela by employee noted below
X
Processed by: Date
May 16, 2008
Report ID: EHS00024v003
Print Date -Time: 5/16/2008 1:31:45PM
Page 1 of 1
Permit #:
Owner:
Applicant:
Permit Type: RNEW CaCommercial, R=Residential + NEW, REPair, VauLT
Parcel #: 1311-18- - -
Location: 9350 CR 13
Legal Description:
Installer:
WELD COUNTY DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT
1555 NORTH 17TH AVENUE
GREELEY, CO 80631
PHONE (970) 304-6415 FAX (970) 304-6411
SP -0300245 Sec/Twn/Rng: 18-02-67
MCCONNELL JACQUELINE
LEON BACKHOE SERVICES
Finaled
Status: ISSUED
Applied: 06/26/2003
Issued: 06/27/2003
Finaled: rips -1 Q
sS
Description: MODULAR
Commercial: N
Residential: Y
# of Persons: 2 Basement Plumbing: Y
# of Bedrooms: 3 Bathrooms - Full: 2 3/4: 0 1/2: 0
Acres: 2.5
Water Public: N Water Source:
Water Private: Y Cistern: N Well: Y Well Permit #: 247857
Percolation Rate: 12.5 Limiting Zone: 8 ft 0 in Description:
% Ground Slope: 2 Dir: NW Soil Suitable: (Y/N) Y
Engineer Design Required: (YIN) N In 100 Year Flood Plain: (YIN) N
Minimum Installation
Septic Tank: 1000 gallons Absorption Trench: 549 square feet
or Absorption Bed: 780 square feet
Actual Installation
Septic Tank: )0\gallons Absorption Trench: `4 square feet
WOO Absorption Bed: 0 square feet
Design Type:
Chambers
NOTICE
The issuance of this permit does not imply compliance with other state, county or local regulatory or building requirements, nor shall it
act to certify that the subject system will operate in compliance with applicable state, county and local regulations adopted persuant to
Article 10, Title 25, CRS as amended, except for the purpose of establishing final approval of installed system for issuance of a local
occupancy permit persuant to CRS 1973 25-10-111 (2).
This permit Is not transferable. The Weld County Department of Public Health and Environment reserves the right to impose
additional terms and conditions required to meet our regulations on a continuing basis. Final permit approval was contingent upon the
final inspection of the completed system by the Weld County Dcpartm t of Public ealth, Environment.
x
Form: S_PLAN
"AV
Environmental Health Specialist Date
•
gCD
CUamuz5
64
6 D
f
MST rJ SRscr
exu46 at;
voi_tP CAr l0ly 0 f- i �J
Ti2uvc it `ToD -cry
Wk LL Ivy _tb ► NSF' ,-j--
PWA -f
Vou4dAjdol,
CSAAlt
IDVQ/'
°0j--)J,T!*
FOR OFFICE USE ONLY
ISDS APPUCATION FLOW SHEET
Owner. M C. C a na l C}q Q
Location:
Date
B
Permit#: 53;5
Legal Description;
Comments
Parcel Number Received
� "`f"
I *
Information Form Complete
_
Authorization R�
\
Map Drawing Received
Flood Plain? Yes/No
.
Ki
Site Inspection Date
6-e14.c:5-
Sq,�
_.
Engineer Design? Yes/No
N
Date Engineer Design Received
Customer Notified? Yes/No
Date Staff Approval Sent
Date Staff Approval Reed
Pero Data Entered In Computer
lope/0
MS
Date of BOH Approval
•Eng Approval Letter Sent
(Letter, Permit, BOH Review)
Date of Final Inspection
Sc15/C
I,
Eng Final Inspection Letter Reed
1
Variances Needed? Yea/No
Sent Variance Staff Approval
teed Variance Staff Approval
Frj tj
Variance BOH Approval
Variance BOH Approval Sent
(Variance, BOH Review)
Additional Comments
M:\ENV1R0NMJMAL HEALTH SERVICESISt;YTIOFIAWSUEET
WELD COUNTY DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT
1555 NORTH 17TH AVENUE
GREELEY, COLORADO 80631
PHONE (970) 304-6415 FAX (970) 304-6411
Permit #:
Owner:
Applicant:
Permit Type:
Parcel #:
Location:
Legal Desc:
SP -O300245 Sec/Twn/Rng: 18-02-67
MCCONNELL JACQUELINE
LEON BACKHOE SERVICES
RNEW C=Commercial, R=Rcsidcntial + NEW, REPair, VauLT
1311-18- - -
9350 CR 13
PERMIT
Applied: 06/26/2003
Description: MODULAR
Commercial: N
Residential: Y
# of Persons: 2 Basement Plumbing: Y
# of Bedrooms: 3 Bathrooms - Full: 2 3/4: 0 1/2: 0
Acres: 2.5
Water Public: N Water Source:
Water Private: Y Cistern: N Well: Y Well Permit Number: 247857
Percolation Rate 1,? ,S Limiting Zone> 8 ft in Description
% Ground Slope ? Direction IJ\-1 Soil Suitable (Y/N)
Engineer Design Required (Y/N) 1,\‘ In 100 Year Flood Plain (Y
Li
From the application information supplied and the on -site soli percolation data the following minimum installation specifications are
required:
Septic Tank I pdo gallons, Absorption Trench 5'{4 square feet
or
Absorption Bed ?-i square feet
Chambers
IS
S
In addition, this permit is subject to the following additional terms and conditions:
AL -c_. y c>.1 S A P L--(
NOTICE
This permit is granted temporarily to allow construction to commence. This permit may be revoked or suspended by the Weld County
Department of Public Health and Environment for reasons set forth in the Weld County Individual Sewage Disposal System
Regulations including failure to meet any term or condition imposed thereon during temporary or final approval. The issuance of this
permit does not constitute assumption by the department or its employees of liability for the failure or inadequacy of the sewage
disposal system.
This permit Is non transferable and non refundable. Before issuing final approval of this permit the Weld County Department of
Public Health and Environment reserves the right to impose additional terms and conditions required to meet our regulations on a
continuing basis. Final permit approval is contingent upon the final inspection of the completed system by the Weld County
Department of Public Health and Environment.
Form: S_PERM1TN
Envir
ental Health Specialist Date
WELD COUNTY DEPARTMENT OF PUBLIC HEALTH & ENVIRONMENT
1555 NORTH 17TH AVENUE, GREELEY, CO 80631 PHONE: (970) 304-6415 FAX: (970) 304-6411
WEBSITE: WWW.CO.WELD.CO.US
Permit Number: SP -0300245
06-26-2003 Amount: $375.00 Payment Method:
Owner Name: MCCONNELL JACQUELINE
Applicant Name: LEON BACKHOE SERVICES
Parcel Number: 131118
Location: 9350 CR 13
Account Code
2560-41400-4221-4203
2560-41400-4221-4203
2560-41400-4221-4203
2560-41400-4221-4203
Description: MODULAR
Commercial: (Y/N) N
Number of Persons: 2
Number of Bedrooms: 3
Water Public: (Y/N) N
Water Private: (Y/N) Y
APPLICATION / RECEIPT
Initials: MS
Receipt Number: HAP -03247
Check Notation: 6110
Description
New Septic Permit
Repair Septic Permit
Vault Permit
Variance Request
Residential: (Y/N) Y Acres:
Basement Plumbing: (Y/N) Y
Bathrooms: Full - 2 3/4: 0
Water Supply:
Cistern: (Y/N) N
2.5
1/2: 0
Well: (Y/N) Y
Amount
$375.00
$0.00
$0.00
$0.00
Well Permit Number: 247857
TERM$ AND CONDITIONS
A permit fee, as set by separate ordinance of the Board of Weld County Commissioners, shall be required of applicants for new individual sewage
disposal systems (ISDS), payable at time of application. Permit fees are non-refundable; permit applications are non -transferable. If both a
building permit and an ISDS are issued for the same property and construction is not commenced prior to the expiration date of the building permit,
the ISDS permit shall expire at the same time as the building permit. If an ISDS permit is issued for a property that does not require a building
permit, the ISDS permit shall expire one year after its issuance if construction on the septic system has not commenced. Any change in plans or
specifications after the permit has been issued invalidates the permit unless approval is secured from the Health Officer or his/her designated agent.
Expired permits can be renewed by payment of the permit fee only if:
A. There has been no change in the plans and specifications of the proposed system as set out in the original application or such change is reviewed
and approved by a Division Representative.
B. The surrounding land, its use or zoning has not changed so -as -to cause the original application not to be acceptable under these regulations.
NOTICE
The completeness of this application is conditional upon further mandatory and additional tests and reports as may be required by the Weld County
Department of Public Health and Environment (WCDPHE). The issuance of the permit is subject to such terms and conditions as deemed necessary
to insure compliance with rules and regulations adopted under article 10 title 25, CRS as amended. The applicant certifies that the proposed system
will not be located within 400 feet of a community sewage system. The undersigned certifies that all statements made, information and reports
submitted herewith are, or will be, represented to be true and correct to the best of his/her knowledge and are designed to be relied on by the
WCDPHE for evaluation for purposes of issuing the permit applied for herein. Applicant further understands that falsification or misrepresentation
may result in the denial of the application or revocation of any permit granted, and in legal action of perjury as provided by law.
C -J6 -v3
Owner/Applicant Date
Form: RT_HAPP
SEPTIC INFORMATION FORM
To obtain an I.S.D.S. permit, one must file an "application for Individual Sewage
Disposal System" at the Weld County Environmental Health Services office and
pay the application fee. A "repair" fee shall be charged for the expansion,
replacement, or repair of an existing system. The following information must be
• provided on the septic information form.
COLORADO
13/I/� 3000 6 7
63
PARCEL NO. L0-rA 1311- 1k'- 3i'& ' (1 DIGIT NUMBER)
CAN BE OBTAINED F OM THE ASSESSOR'S OFFICE AT (970) 353-3845 EXT 3650
PROPERTY OWNER: A 9 up- 1, ti e %ti'1 t < pn�n1 c 1/
MAILING ADDRESS: 93 S 6 (A I e Id ?TI Rd 13 CITY 10 , b ,,,o,, : ST £Q ZIP 6-03-0
(r
HOME PHONE: (.22,23) 'I) WORK PHONE (303) g33 -azerr FAX ( )
APPLICANT NAME: I F 1 .1�Ask 1,c 0- Se/ u:., E -.s
MAILING ADDRESS: 3-513 "'. As h 5 ' CITY kEEj►1 -c J 1ST Co ZIP ea 64/3
HOME PHONE: (i 03) ) 3a -4S 56 WORK PHONE (303)5c/-33o7a7 FAX (33i 7-..t ?- SIS�Fr-
LEGAL DESCRIPTION PTaU�1/ PT5' SEC le TWN RNG A2 W ACRESQ7. Saro27
SUBDIVISION "/A LOT A BLOCK FILING
DESCRIPTION OF BUILDING (EX: HOUSE, MOBILE HOME, MODULAR, SHOP, OFFICE) (16 [` u/A
SITE ADDRESS 935 O WE-, CT ` _
DIRECTIONS TO SITE
NEW PERMIT REPAIR PERMIT VAULT PERMIT
$375 $375 $150
IF OBTAINING A REPAIR PERMIT, PLEASE LIST PREVIOUS OWNERS OF THE PROPERTY:
FLOOD PLAIN
RESIDENTIAL YE / NO COMMERICAL YES
NUMBER OF PERSONS c:2 BASEMENT PLUMBING 'YE / NO
NUMBER OF BEDROOMS 3 BATHROOMS: FULL 3/4 I/2
WATER SUPPLY: PUBLIC YES
PRIVATE
CENSUS TRACT 20 0 I
NAME
CISTERN YES N • WELL YE `'/ NO WELL PERMIT #07'{7 es7
PERC HOLES MARKED FOR INSPECTION BY SPECIALIST
June 23, 2003
To Whom It May Concern:
I, Jacqueline McConnell as owner of the property located at 9350 Weld County Road 13,
Longmont, Colorado, give authorization for Leon's Backhoe to pull the septic permit.
If you have any questions, please give me a call at my work 303-833-2388 or home 303-833-
2647, or my contractor Harmony Horton at 303-913-5214.
Sincerely,
{
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1.
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a'
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per.
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/
20' JOINT ACCESS
EASEMENT
RECEPTION # 2744907
ACCESS
ROAD
N
Q
to
t' FOUND 1 1/2"
rieorite ALUM. CAP
LS# 13446
M: 364.26' S89'43'24"W
LOT8
5.473 ACRES +/--
:co
N
0
1•--20' EXISTING ACCESS EASEMENT
PER AMRE 477
M: N89'58' 12"W . 37O:91'
R: N90'00`00•'W 37UJ • ti. . "EOUN
krJ�!
�... i•Tpr/triui�'i1:.•IeieM1: d.' -a.,Tb.I. •�`C�J•r %% Zit*
SUBMITTED FOR:
TITAN BUILDERS
9350 WELD COUNTY ROAD 13
WELD COUNTY, COLORADO
PERCOLATION TEST RESULTS
JUNE 13, 2003
PROJECT # 031-0485
SUBMITTED BY:
PAUL R. BRYANT, P.E.
COLORADO ENGINEERING
& GEOTECHNICAL GROUP, INC.
2931 NORTH U.S. HIGHWAY 85
CASTLE ROCK, COLORADO 80109
303-688-9475
#031-0485
PERCOLATION TEST RESULTS
On June 11, 2003, percolation tests were conducted on the site known as
9350 Weld County Road 13, Weld County, Colorado.
The percolation tests were performed in accordance with Weld County regulations
which pertains to individual sewage disposal systems.
The percolation rates of these tests are reported in minutes of time per inch of water drop.
The field percolation rate is the average of all the test holes observed in the proposed
leaching area.
SOIL PROFILE HOLE ... 10 feet deep
0' to 10' Silty sand (3/12" Blows)(SM)
PERCOLATION TEST HOLE#1 37 inches deep Hole #4
Percolation Rate = 9.4 minutes per inch Perc rate
PERCOLATION TEST HOLE#2 36 inches deep Hole #5
Percolation Rate = 17.8 minutes per inch Perc rate
PERCOLATION TEST HOLE#3 36 inches deep Hole #6
Percolation Rate = 8 minutes per inch Perc rate
FIELD PERCOLATION RATE 13 minutes per inch
A soil sample was taken from the soil profile hole at a depth of four feet and consisted of
5 % moisture, 0 % gravel, 82 % sand and 18 % minus 200 material.
37 inches
10 min./in.
36 inches
20 min./in.
37 inches
10 min./in.
P-1
P -1J, P-6
DRIVEWAY
W
0
0 10 20 30 40 50
GRAPHIC SCALE IN FEET
SCALE: 1^ = S0'
SLOPE 1.2%
P-2
rM b
PR • FILE
P-3
P-5
*TH•2
.TH-1
FLAT
S.W. PROPERTY CORNER
o ❑ 0 0 ❑ o ❑
f
SLOPE 1-2%
FROM
TO
OI$TAMCM
•IARIMO
S.W. Property Corner
TH-1
110'
N46E
111-1
1H-2
32'
N16W
1H-1
PROFILE
115'
NJW
PROFILE
P-1
26'
N25W
PROFILE
P-2
8'
N72W
PROFILE
P-3
20'
511W
1
PROFILE
P-4
16'
523E
PROFILE
P-5
6'
HINE
PROFILE
P-6
24'
H5E
SITE PLAN
OWNER" BUILDER`" TITAN BUILDERS- JOB '#: -031-0485
JOB ADDRESS: 9350 W.C.R. 131 WELD COUNTY
CASTLE ROCK OFFICE
2931 N. HWY 85
- -7-CASTLE—ROCK; -GO-89109c -
(303) 688-9475
FIGURE 1
F FOM : LEON BACKHOE SBRV I CE INC
PHONE NO. : 3036379771 Jul. 25 2083 07:54AM P2
• - .7.7^....• •-r .. -...•
Serving Colorado
For Forty Years!
1963 - 2003
ERIE PRE -CAST CONCRETE PRODUCTS, INC.
4060 Weld County Road 1
ERIE, COLORADO 80516
(303) 828-43338 (303) 828-3949 Fax
CUSTOMER'S 0REM nro.
PHONE
DATE
N ALfil M1 4v)aitasiVe
ADDRESS ,
t
Tax
R" 'weY
TOTAL
AB car.. rd Ne,rt#4 goods ...,r e..mPTC.lded of this bel.
41509
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