HomeMy WebLinkAbout20131471.tiffScanning Cover Sheet
for
Septic Permits
Permit #
Permit Type:
Situs Street Address
Situs City, State, Zip
SE -0600083
Health / Residential / Statement of Existing
2621 W C ST 1N
Sec/Town/Range: 36 -06N -66W
Parcel # (12 digits)
Owner Full Name:
Owner Address:
Contact Name:
Contact Address:
080536000009-R1376586
SOVEREIGN LISA
PO BOX 114
KERSEY,CO 80644
SOVEREIGN LISA
PO BOX 114
KERSEY,CO,80644
Application Status: RECORDED
Application Date: 12/15/2006
Owner Phone #: 970.356.9439
Contact Phone# 970.356.9439
Information above has been Verified in Accela by employee noted below
(pant
Processed by:
September 24, 2008
Date
Report ID: EHS00024v003
Print Date -Time: 9/24/2008 8:44:17AM
Page 1 of 1
WELD COUNTY DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT
1555 NORTH 17TH AVENUE
GREELEY, COLORADO 80631
PHONE (970) 304-6415 FAX (970) 304-6411
STATEMENT OF EXISTING SEPTIC PERMIT
Permit #:
Owner:
Applicant:
Parcel #:
Location:
Legal Desc:
SE -0600083
SOVEREIGN LISA
SOVEREIGN LISA
0805-36- - -
2621 C ST
Sec/Twn/Rng: 36-06-66 PERMIT
Applied: 12/15/2006
Description: HOUSE
Commercial: N Residential: Y Acres: 5
# of Persons: 0 Basement Plumbing: N
# of Bedrooms: 3 Bathrooms - (Full): 1 (3/4): 0 (1/2): 0
Water Public: Y Water Source: CITY OF GREELEY
Water Private: N Cistern: N Well: N Well Permit Number:
Septic Tank: 750
Absorption Trench: UNKN
Absorption Bed: UNKN
sq. ft.
sq. ft.
Tank Material: CONCRETE
Year Installed: UNKN
NOTICE
The property owner/agent has certified by Notary Seal that the above described septic system is in fact installed as described, and
exists at this time on the parcel identified above by the parcel number and/or legal description, and further states that the system
IS / IS NOT in good working order and to the best of his/her knowledge IS / IS NOT failing to function properly.
The property owner/agent further understands that any falsification or misrepresentation may result in the revocation of any permit
granted based upon this information hereby submitted and in legal action for perjury as provided by law.
The Statement of Existing Record relies on information the property owner or his/her representative provides, under oath, indicating
current status of the system and representing to the best of his/her knowledge that the system IS / IS NOT failing to function properly.
Issuance of the Statement of Existing Permit for any system does not constitutLassumption that the site was evaluated or inspected
during any phase of construction by this Department to meet regulations.
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Ep'vironmental Health Specialist Date
Form: S_EXIST
PARCEL#
PROPERTY OWNER
WELD COUNTY DEPARTMENT OF PUBLIC
HEALTH AND ENVIRONMENT
1555 N. 17TH AVENUE
GREELEY, COLORADO 80631
PHONE: (970) 304-6415
FAX: (970) 304-6411
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ORG PE
REPAIR #
LOAN #
ISDS # w) Ra
STATEMENT OF EXISTING FOR SEPTIC SYSTEM
(PLEASE FILL OUT IN BLACK INK ONLY)
Q8oc.(Q cJO�i DO
MAILING ADDRESS G7 Z
HONE NO.
City
DESCRIPTION OF BUILDING (ex. house, mobile/modular home, shop, office
SITE/LOCATION ADDRESS
LEGAL DESCRIPTION PT
SUBDIVISION
CENCUS TRACT
(402i LD-
COMMERCIAL YES
NUMBER OF PERSO
BEDROOMS 3
WATER SUPPLY - PUBLIC
PRIVATE
PT SECTION,
LOT
LOT SIZE/ACRES
RESIDENTIAL
BASEMENT PLUMBING YES
BATHROOMS FULL
N
WELL YES / :S1 CIST
(t) ,7Um3
fib N
State/ Zip
TOWNSHIP ( RANGE
FILING
BLOCK
3/4 1/2
SYSTEM SIZE: Septic tank material is constructed of&ink- _ and has
FIELD: Trench square feet or Bed square feet AR INSTALLED (/j
You are required to draw a diagram of the system on the reverse side of this form in black ink only and indicate
location, length, width, and distance from the dwelling.
L/CISTERN#
gallons clpac'
The undersigned property owner hereby certifies that the above described septic system is in fact installed, as described,
d exists at this time on the parcel of ground identify 1 by the abov • legal description and further states that the system
is not in good working order and to the best of is lh jknowledg • is is not failing to function properly.
isrepresentation may result in revocation of any permit granted based
egal action o perjury as provided by law.
urther understand that any falsification or
upon this in . rm'6n hereby submitt7
r
i
1
DATE
Subsceb, ed and swor►i before m
by o -q ✓fit"
Witness my hand a official seal.
DATE
, 20 0 6'
My commis i ; expires:
NO ' ARY PUBLIC
STATEMENT OF EXISTING INSPECTION REVIEWED BY
ENVIRONMENTAL HEALTH SPECIALIST DATE
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' WELD COUNTY DEPARTMENT OF PUBLIC HEALTH & ENVIRONMENT
1555 NORTH 17TH AVENUE, GREELEY, CO 80631
PHONE (970) 304-6415 FAX (970) 304-6411
STATEMENT OF EXISTING RECEIPT
Copy Reprinted on 12-15-2006 at 16:39:53
Receipt Number: HES-06065
Payment Method: Check
Owner Name:
Applicant Name:
Permit Number:
Parcel Number:
Site Address:
Location:
SOVEREIGN LISA
SOVEREIGN LISA
SE -0600083
080536
Amount: $10.00
Notation: 1010
Date: 12-15-2006
Initials: MS
Total Fees:
This Payment:
$10.00
$10.00
Total All Payments: 10.00
Balance: $0.00
Account Code
256041400-4221-400
Description
Statement of Existing
Amount
$10.00
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Received By
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COLORADO
DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT
1555 N 17TH AVE
GREELEY, CO 80631
WEBSITE: www.co.weld.co.us
ADMINISTRATION (970) 304-6410
FAX (970) 304-6412
PUBLIC HEALTH EDUCATION AND NURSING (970) 304-6420
FAX (970) 304-6416
ENVIRONMENTAL HEALTH SERVICES (970) 3Q4-6415
FAX (970) 304-6411
December 27, 2006
Lisa Sovereign
Post Office Box 114
Kersey, Colorado 80644
RE: Lisa Sovereign ISDS No.: 06082
Permit No.: SE -0600083
On December 18, 2006, an evaluation of the existing individual septic disposal system at:
2621 C Street, Greeley;
Section 36, Township 06 North, Range 66 West,
was conducted by Stephen J. Wiatrowski, an Environmental Specialist of this department.
Based on all available data, it cannot be determined if the system is adequately sized for the structure
served. However, there were no signs of failure at the time of the inspection. This evaluation is based on
a final treatment capacity for a 3 bedroom residence.
The inspection did reveal a grey water line that discharges on to the ground. This condition is in
violation of Section 30-2-10 of the Weld County Code which states in part "Under no condition shall
sewage or effluent be permitted to be discharged upon the surface of the ground..."
This Department requires that the grey water line be abandoned, and the effluent be routed to the septic
tank. Be advised that this action may require a pei alit from this Department, or the building department.
Be advised, neither the County of Weld nor any of its agents or employees undertake or assume any
liability to the owner of the above property, to any purchaser of the above property or to any lending
agency making a loan on the above property or in the report.
This inspection was conducted for the purpose of determining compliance with current regulations and
for detecting health hazards observable at the time of inspection. This does not constitute a warranty that
the system is without flaw or that it will continue to function in the future. Inspections requested during
periods of snow cover and high soil saturation may be of questionable value to potential buyers due to
adverse conditions. Evaluations based on Statements of Existing (S.O.E.) relies on information the
property owner provides, under oath, indicating current status of the system and representing to the best
of his/her knowledge the system is not failing to function properly.
If we can be of any further assistance, please contact our office at (970) 304-6415.
Sincer
Stephen J. Wiatrowski
Environmental Health Specialist
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FIELD INSPECTION FORM
ISDS Request No:
Plan Referral No.:
Date Received:
Received By:
Fee:
Date Inspected:
06082
RE -PENDING
12/15/2006
MS
$150.00
Owner Name: Lisa Sovereign Phone of Contact Person: 970.356.9439
Mailing Address: Post Office Box 114 Kersey, CO 80644
Site Address: 2621 C Street, Greeley, CO 80631
Legal Description: PT PT Sec 36, Twn 06 N, Rng 66 W
Subdivision: Lot Blk Flg
Water Supply: GREELEY Residential/Commercial
Permit on Record: SOVEREIGN LISA Permit No: SE -0600083
System Size: Tank 1150 gallons Trench Oil\L. square feet
Total Acres: 5
S.O.E.: Y
Bed 44 k square feet
Percolation Rate: minutes per inch SoilType:
Engineer Design: Yes/No Percent Ground Slope
ystem iden
ation(s)
Description:
Persons:
Bedrooms:
Bathrooms:
Bsmt Plumb:
T -ex'
odate
Fjnvironmental Heah Specialist
ed below to
Current Flow
HOUSE
0
3
1
N
eptic system
ropo
Direction
ove IS/IS NO . s i i icient size : accom
e(s) serve • . • s system.
Additions
RE -PENDING
0
0
0
uired/Reco • en • - d to have t
alteratio
e structure
roposed�
►ilitM�=
Proposed Total ape/
HOUSE t(A 0 "Al)
1 Vi O i kvuDP
Cope
a -Z- 76
ing alterations o
/0 - c24 -a6
Date
3
N
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
ISDS APPLICATION / RECEIPT
12-15-2006 Payment Method: Check Notation: 1010 Initials: MS
ISDS EVALUATION NO:ISDS-06082
Lisa Sovereign
Location: 2621 C ST
Receipt Number: ISDS-0177
Account Code
2560-41400-4410-4203
Description of Building:
Current Flow
Desc HOUSE
Persons 0
Bedrooms 3
Bathrooms 1
Bsmt Plumb N
Water Source: GREELEY
Description
ISDS Evaluation
Additions
RE -PENDING
0
0
0
Amount
$150.00
Proposed Total
HOUSE
0
3
1
N
NOTICE
The undersigned hereby certifies that all statements 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 Weld County
Department of Public . ealth and Environment in evaluating the same for purposes of septic systems compliance. [ further understand that any
r misr presentation rparresult in the denial or revocation of any evaluation granted based upon said evaluation and in legal action of
idk. by law.
falsificat of n
perjury,ars pro
Ow ‘r/applicant
rm: R 1SDS
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COLORA
SITE ADDRESS OR LOCATION:
PARCEL NO:
ISDS NO:
DATE RECEIVED:
RECEIVED BY:
FEE:
INDIVIDUAL SEWAGE DISPOSAL
SYSTEM EVALUATION
(St
(THIS CAN BE OBTAINED FROM THE ASSESOR'S OFFICE AT (970) 353-3845 EXT 3650) •
PROPERTY OWNER: /954.
MAILING ADDRESS: f.01&O't
APPLICANT'S NAME: /4 5CA
APPLICANT ADDRESS: 2-V
(IF D FERENT F OM OWNER)
(I D FFEREN F WNER)
I
LEGAL DESCRIPTION: PT:
SUBDIVISION:
PT:
WATER SOURCE:
LOT:
9 -
SEC:
PHONE:
C
BLK:
RNG:
TWN:
ORIGINAL OWNER OF SEPTIC SYSTEM: ki
PERMIT NO:
FLG:
ACRES:
CURRENT FLOW
DESCRIPTION:
(House, Modular, Shop, Rec Exemp)
PERSONS:
BEDROOMS:
BATHROOMS:
BASEMENT PLUMBING: iv --2
ADDITIONS
MIkt,
SOE: YES / NO
PROPOSED TOTAL
NEITHER THE COUNTY OF WELD NOR ANY OF ITS AGENTS OR EMPLOYEES UNDERTAKE OR ASSUME
ANY LIABILITY TO THE OWNER OF THE ABOVE PROPERTY, TO ANY PURCHASER OF THE ABOVE
PROPERTY OR TO ANY LENDING AGENCY MAKING A LOAN ON THE ABOVE PROPERTY OR IN THE
REPORT.
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