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APPLICATIL., FOR INDIVIDUAL SEWAGE D,,,POSAL SYSTEM No.
WELD COUNTY HEALTH DEPARTMENT New
ENVIRONMENTAL HEALTH SERVICES
1516 Hospital Road, Greeley, CO 80631 Repair —,
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OWNER ` ADDRESS3 ''t `X. 270 } 1, , �.r,F;1 J„i r * •- 4
,« PHONE
ADDRESS OF PROPOSED SYSTEM": ` S - F -,_.. T d t
LEGAL DESCRIPTION I OF SITE: PT `,__S_=._ , T___t_, R__.5"__
SUBDIVISION. r'4 r 1`"r� t-" r` C`AI_ LOT -3 , BLOCK , FILING
USE TYPE: RESIDENTIAL INSTITUTION-
COMMERCIAL �-,'-' . - S'. Cti�lr; (..t�+'
OTHER -
SERVICES: PERSONS c---__. BATHROOMS_&""'""' I LOT SIZE �c.c K:a C I I S 1
,eIIS � t�
BEDROOMS_ `-'" BASEMENT PLllty181NG WATER SUPPLY
TYPE OF SEWAGE DISPOSAL REQUESTED:
Applicant acknowledges that the completeness of this application Is conditional upon further mandatory and additional tests
and reports as may be required by the Weld County Health Department to be made and furnished by the applicant or by the
Weld County Health Department for purposes 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 adopted under Article 10,
Title 25, CRS 1973. as amended. The applicant certifies that the proposed system will not be located within 400 feet of a com-
munity sewage system. The undersigned hereby certifies that all statements made, Information and reports submitted here-
with and required to be submitted by the applicant are, or will be, represented to be true and correct to the best of my knowl-
edge and belief, and are designed to be relied on by the Weld County Health Department 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 applicatiof or revocation of any permit granted based upon-said application and in legal action for perjury as provided by law.
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Application tee . _— ' .r�?;' ,� ,• r. ,;%. r ,,.:
y
Rec'd by ' Date - 'I_d Owner/Agent,Signature Date
• FOR DEPT. PERCOLATION RATE _ WATER TABLE DEPTH -' *%
USE ONLY SOIL TYPE - '?'.•- -5 V " " C /,>`,., PERCENT GROUND SLOPE-4-c"4:::
REQUIRES ENGINEER DESIGN ( )YES Q4 No
INDIVIDUAL SEWAGE DISPOSAL SYSTEM PERMIT
From the application Information supplied and the on-site soil percolation data, the following minimum installation specifi-
cations are required: ,
SEPTIC TANK f-1 ` .;:� GALLONS, ABSORPTION TRENCH " _ SQ. FT.
or
ABSORPTION BED -s SO. FT.
In addition, this Permit is subject to the following additional terms and conditions:
This Permit is granted temporarily to allow construction to commence. This Permit may be revoked or suspended by the Weld
County Health Department 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 oi,,flnat approval. The Issuance of this Permit does not
constitute assumption by the Department or Its ernployeet pi,Iia�il(t)9 foc t e failure of Mad ' cy of the sewage disposal,system.
-
Envj ,pinental Specialist • Date
This Permit is not transferrable and shall become void if system construction has not commenced within one year of its Issuance.
Before issuing final approval of this Permit the Weld County Health Department 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 in-
spection of the completed system by the Weld County Health Department. i
SYSTEM CONTRACTOR FINAL INSPEC O F513,0y
• SYSTEM ENGINEER _ APPROVAL
En ironmen I Specialist
The Issuance of this Permit does not imply compliance with other stater county jr 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 pursuant to Article 10, Title 25, CRS 1973, as amended, except for the purposes of establishing final approval of an
Installed system for issuance of a local occupancy permit pursuant to CRS 1973 25.10.111 (2).
Original-Applicant; Copy-WCHD V 2011-0268
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DAVID E. MO0RE, P.E. 4
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May 24 , 1994
Weld County Health Department
Environmental Health Services
1516 Hospital Road, Greeley, CO 80631
Attention: Jeff Stoll
I have reviewed the sewage disposal permit and the owner has
verified the location of the existing septic tank and absorption
trenches on Bruce and Janet Richard ' s property. The existing
system will adequately serve the two planned bathrooms and grease
trap the Richard' s plan for their auto restoration building.
If you have further questions you may call me at the number listed
below.
• Sin r ly,
David E . Moore .E .
Oa Rfo_%
Gage nine CiPS
* 22495 *i
*IV••'le•�S.... I
3122 Rock Creek Drive ■ Broomfield, Colorado 80020 ■ (303) 466-5988
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