HomeMy WebLinkAbout992742.tiff FORM N STATE OF COLORADO ^ _"r office Use only
GWS-12 OFFICE OF THE STATE ENGINEER PERMIT NUMBER30/89 818 Centennial Bldg.,1313Sherman St.,Denver,Colorado 80203
(303) 866-3581 --
FOR INSTRUCTIONS SEE REVERSE SIDE
REGISTRATION OF EXISTING WEIL
1. WELL OWNER 0,
NAME(S) 4:4 r t n t a_ Hen-Ly
Mailing Addressa + � — ----
City, St Zip gf i ini-a-rt. i CJ) 6ocQO l
Phone (303 ) l a-2,'1 - q 9 t ?
Receipt No.
2. WELL LOCATION:� COUNTY Li P_L 4 OWNER'S WELL DESIGNATION
//{/ rect-1 ics9G- 8112_ IJric\Kkr ... _ FlO/al.SF
(aMrecc) (Sty) (State) (Zip)
Ng 1/4 of the tIE 1/4, Sec. cali Twp. I WIN.N. or❑S., Range 4(p El E. or 121/W. (D P.M.
Distances from Section Lines /3g0 Ft from IZN. or❑S. Line, /J'JO Ft. from Lrl . or El,W. Line.
3. The well has historically been used for the following purpose(s); C_ STaG 'EIs"bal
4. Water from the well was first used beneficially by the original owner for the above described purpose(s)
on Q* air- _19 '51 ft,M
S. The total depth of this well is__5o "f/eet •
6. The pumping rate is Jr.c _gallons per minute.
7. The average annual amount of water diverted is leg—Z acre feet
. C t L'_7 Acre or ❑S e feet,
(Number)
8. The land area of home lawn and garden irrigated from this well is: 4uaz
described as: •
(regal Desetiptan)
or as Anal /JPU5 Subdivision Lot(s) 3 Block C Filing/Unit
I (we) have read the statements made herein, know the contents 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.]
9. IN�ame/Title (please type or print) ignature Tatee
Pairi0; L (494.1,y _ t
grelAL 849 /nq 77
owner
FOR OFFICE USE ONLY
992742
.
.1 ri(?iv:i:1D(JAi... rSI :WAG D ISF''(Tf:;AI... :iYzi'1'I:�ir! 1"'E::r=:MI T I It:l,: (:i �';`. ,i E.):
WE L..X) (:.(?E.JN T'Y I IEtat._T I I)E F'AFt:T'I�IE N'r./, , ' . ,
RE:R6:::::
T
i:;HV:CF't(JNMEN Tr;L.. HEAI_.'T H ."•.�ERVIC:;E:::3
I 151Y-.:' 16TH AVENUE:. COURT. GF:E:ELE Y.. CO 8063:1.
35370635 EXT..'''225
// AN -MCOL_E:SI<`r. f...0LA ADDRESS ?72"5 APPALOOSA PH i;'.::Y3) F>.::i9-...; :
.BRIGHTON co .3C)f.,:)1.
?DRESS OF PROPOSED SYSTEM 2?25 APPALOOSA .
BRIGHTON CO 60601
LA... DESCRIPTION OF SITE: NE4 SEC 24 TWP 1 RHO 66
JI<D1:V1::..3:C(71••Ir. (GF'.1::1:::H ACRES'3 LOT 'I BLOCK 5 FILING C)
3E::: TYPE: RESIDENTIAL Or c '/"7,'020
:F:V:I:C:E::;a» PERSONS 1. BATHROOMS 2.00 1..0T SIZE :i. ..50 ACRES
BEDROOMS 3 BASEMENT PLUMBING HO WATER SUPPLY PWELJ.
'F'l._ICATIC)N FEE $125.00
:c 'D BY CINDY SALAZAR . a:IGHEI5 . BY MARILYN L. C3REII-'L
DATE 11./0(3/93( DATE 11/00/93
:f4('OL.ATION RATE 5.,0 MIN 'PER INCH • LIMITING ZONE 8 FE1::A-
:IL.. TYPE SUITABLE PERCENT GROUND SLOPE 0"., DIRECTION
O1.JIRE a ENGINEER DESIGN NO -IN 100 YEAR FLOOD PLAIN ZONE NO
OM THE APPLICATION INFORMAT:I:ON • SUPPI..:iEX) .AND THE ON-SITE SOIL PERCOLATION DATA
I FOLLOWING MINIMUM INSTALLATION SPECIFICATIONS ARE:: REQUIRED::: {{
SEPTIC TANK 1000 GALLONS. ADSORPTION 'TRENCH f4:`.)5 SO. rt.
- ABSORPTION DID 570 SO. -F•' . �
MDDIIION. THIS PERMIT I'.: u:;JI:::CT -T C) THE FOLLOWING ADDITIONAL TE <3 .AND
NDIT:ION�IS� .. .....�.I�E .. 4,1,,re.f .....£C.,IYm..>{_ ........Z.s/�.,s........, ..s_:._. L_ »._. »..w._
IS PERMIT ,C`3 GRANTED TEMPORARILY TO AI_1_OW .C>(m$TRL.JCT:I:ON TO COMMENCE. THIS PERMIT
`c' BE REVOKED OR SUSPENDED BY THE WELD COUNTY HEALTH DEPARTMENT I ME N'T' FOR REASONS SET:.;:
:'T•H IN THE WELD COUNTY INDIVIDUAL ;SEWAGE:`: DISPOSAL SYSTEM REGULATIONS.-INCLUDING;
IL..URE TO MEET ANY TERM OR CONDITION IMPOSED THEREON DURING. TEMPORARY OR FINAL a
s=:OVAL.. THE ISSUANCE OF THIS PERMIT DOES NOT 'CONSTITUTE ASSUMPTION BY •T'HE"'.
2'AR•TMLNT OR ITS EMPLOYEES OF LIABILITY' FOR THE FAILURE OR INADEQUACY OF THE • '
JADE DISPOSAL SYSTEM.
'',... PAM SMITH I-I . . • 11/12/93
P/ // -/7- ? 3 ENVIRONMENTAL SPECIALIST DATE..
a..7
PERMIT IS NOT TRANSFERABLE AND SHALL BECOME VOID IF SYSTEM CONSTRUCTION HAS
COMMENCED WITHIN ONE YEAR OF :I:•r.. ISSUANCE. BEFORE ISSUING FINAL APPROVAL OF
:S PERMIT THE WELD COUNTY HEALTH DEPARTMENT RESERVES THE RIGHT• ,T'O -IMPOSE ADT1-•
1H -IL TERMS AND CONDITIONS I- EUUI1tiED -TO, MEE:-T' OUR RE'::( LJ1...A'T•IONS • ON. A' CONTINE.JINJ.S BA-
i. FINAL NAL_ PERMIT APPROVAL IS CONTINGENT UPON THE FINAL_ INSF'E=.`cTON OF THEE _COM-- '
:TED SYSTEM BY THE WELT) COUNTY HEALTH DEPARTMENT. i .R
•
;TEE INSTALLER AI...LE R ke/ _.,ye).. ��..__...... ......._..__._._' .-. FINAL. INSr•'" :'T .N 4T-Ir: 1i
r1•E::I*1 ENGINEER .... .7-7- AF�'F'I{oVAI
'1 OF SYSTEM M INST ;I...I...I :I) E:I••IV:L :ONMENTA. .)PL .::CAE._I;:;'Y »» *-
;SUANCE_ OF. THIS PERMIT DOES NOT IMPLY COMPLIANCE WITH (OTHER STATE. COUNTY:: :
L_uCAL_ REGULATORY Y OR BUILDING REQUIREMENTS. NOR SHALL-IT ACT T(1 CERTIFY THAT
SUBJECT SYSTEM WILL OPERATE RA'T'E .IN COMPLIANCE W-i:TF•I i d I—'I...iI:C3Fd-jLE STATE, LOLHN.;T Y :.AND .
AL REGULATIONS ULAT:10M% ADOPTED I Ek;:3UANT TO ARTICLE :L0, TITLE 0, CRS 1973, AT AML.I+IDFD,
ERT FOR THE: PURPOSE: OF ESTABLISHING TABLISE••CING FINAL_. APPRCOVAL.. OF AN INSTALLEDSYR*FrrrIP
• ;5* ;6
Hospital Rood •• • . i..)/1 • rl?'ns
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91fXTS.7 i S
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i' • r rnda. :, yt ..
/ 'y;: urccicii;Oo4 'j s . p1=RMl �.,C' ct ' •_x .
Ph,p�353;0540"'-:•' ' ..,..,:.:::';'..:•••::'..�. .,. ,..��_ -
i,'f• - ••arcs n: :` �y[ar t' 's 7' --. ..�_ • 74s •Nc q`413.4t ,,. - 4 .ti_
�jr" i�
ficoti„n for a ,t to Instoll,.�Corrstrtrct, en lntlirii!of `Sewoge''Disnos�l : . *� f
�y,,r`�...1'n r#P6 z Lo•iCt `C i rsc t .,,.'A J' _flags. • �F r i ' ,� ,,.-.-:47.!....7--,,
1 C. F,--,,�'iy { A
L'i cct:or iv site: Hwy._. • �� ;:d ` .N • , , x" ' +t z
1
> Cc�<ti i�rcrrinrtp. u, yl'�� �c_I `, r ‘,....:•,,,•-•44.44ya s, .:,,. '.
r •,,• Sec;., L1 , .I. N,M W Sulidrv+t. -'r'Ir'Pf,�i t '`"�L t �r Iu K-:
_ _ •C.. ""ES''K1R F�1. ,Y ♦I'r'"""k'}.
LGeneral f.....„•.:,:-..,...:-.,„:` ,` .. �' I.. N.ts• 7:_
Intarrrrotipn; • "- ':� ` *' ::. • F t -�. ', .. ,.•doom. No. Persons''` :' . • -:• . t - w.r,. ti t.,,
k '' R?:.v.
Bo l x. :t: Y? :rw'jf _____ , `as•,: �«..A. i=CrC• Q �V. '�('':,:,.--...**7k.,C .•••••,•.e• }%'': `2
No. otlzs. Basenietlt`Tiurr)bmg� ', :^, >•• + ',.•kltnac,• A .k 1,1)'-'W(...57
',_ YW`'-^"- ron , J:.
Size of Lot_ a c r"t6 ?. .• ...'. ` ,.,rr e):. {f' t='{`'[4rs`3pa ,,,,-„:,..,..4--..,-,. s,., :,..:: to
r
T.
KO supply fir well. give depth,- -.• '. -+. . ,.` :; ,--• t .. •s"':1.4" . _C
New Home• Mobile I force M I `.'`� T:u : ' ~ • fit„ •=, � '
:,�„.a..; .'::.i.'•••••- :r� -' y' r- .I,acsi:ti+�rr. LneOak°p• Y ! '• oM.....?�fi.; .:,
Type of sewage disposal requested ica;_ _ iS: , t y1 -:
-.� Yes G ;. . r
• Se'ti` to nkk _. Priv __ _.Glh1er_ "••••; • •,• ,.a,,:r d Y .. � . ' j,'.
IASr :.S ' cc t r -'�' .::77�C 5. J11,v.,r; _ '! • 7^r'•- Comn3CritS.n'}r.,$.• �'f'",.u, ' `t x `- :L`-••,•` `- -t
'This
Is i �.-4 c goof Vwy[(_ ///'��'lll��_ Y ",.... `-,4• ,7::,,,,:;,....,:,-
4 .`.T", ^z- _;. l _nmrca.._++ ..tea._ 1t'_•
I _ 2�• I'C_ • .'�I,{��� pM4 .1.-. .22.......,-.L.--
f..ra...>.. x'N a • • .:::,,-4.;;- .-.K•'_.^P��w
I,istdilolion Instruc R *• • ,- rr•'�-,`�•- ,'=?�• (Ions 'fM- rr)+n1un1''.�C ul►ct)tcr 'sl"�• -.s :-�.::.'� .�••� , t:-
I • 9,;,.,:p•.7.10... .,�r'':'s ;. is
s e. an,;, j�DD Go y. A .k, • ', ,K 'it. 1.3e I .• • *,f `i ... , 4.,.�bCorption .T.:re e C -,-*-,31.,''. ..4,i....„..,.• .! :: e,• . 75 .
I Other y"4ere'..., sTM ..pr r,..tF 1:. r,„.. _'r :__•• �
i7;44#4,,:''A-2.,•::1,/-.--4",,
— /try
,
' �SCcpoc�c�I)ci ��s� 1ww-� :;,
p _`tea..'..`F ,:'i'fir k f . e s " .
S CCIoI Instructions-. � �. •a ..„,..r.„„„,„ ••' �
T})I': system w Il 1 ,:.4,r; 4s ,S.y. .w,•r,:...•..:-iw..' K&;,,,,ip1?' TT__„"..:t, " '7, it .•••••,..!".1.:."-.„.••
c '
> i l e constructed Hurl !t)tlallccf rrt occordoncc, witl)'4the:abov r ' E
Thi:: sy individual :sewage c" Spg. ifreot,ton . . . . `
, s age dispvsul,systems it• Wc1i1'rCounty,+ ColerOdot ;.,,,c ` Y' `"` '. .1� it `
t`I)i5 )rrtnit h � , • \- :. §.. ,• •;I"�'' ▪ ;: ,.t,.• r :4a "`•=n•:4�,,- .'.•:: :.1:.ahc.::
I shall;a .pPt'r o! the.cciiiiC-'Lime"o 't } '' '`'y' . _
5•:: I„ •'ilcrwfdi'rl icr,r.ptt'' r'_`
shall expire 12 do y6 after rC, - os. , ci ,.tf4 i1r�t.'l iidd�rty rn.r (k ar ,≤ , !_
(((� y- its i:Suorice* 4i.f.�j[7onsiruCtiQ:''ilq ;n_ot';besn C•„ , nc d ±qy -4.,.,:i4.-- �-= ',- �-'
Doti•. •
• - •(..1.0t-4,....;ffIII/ �"','•t'F^4 }k rr,u'•T,./1�'iyl•-MtN,,•�,(Y�/Y.J' '', jM� �••��
' i'r�.Q�Nr1C r.'- �Yf///- � •'� •s� ` * 'F-Ty ` "9'T'' • .il' -a i+
• •�• z ¢'sus. '.' TrF,;•'. ' "^,.. ,,i. ;>r .- :. i. o9) at ` �i.1 . '' ,
:: ' • ,`� } '..•S's':Applrcont -y► , 1 , , E.. 't.'.,
•
The plans On l i µ y ~7 r x -g'.1.4., N
sp<cilicotions as )own r y ><,• a `.:
r 9tc.opPioved:-pendi lg, poylncp•t of permit fc ...
a:�J'"N�_�y::_W�;'g''.+._;3.. .L^'�4 ; m5 .. ,•.•ye ,� •-a .,k Yl 1 ."r' r.o-
' .P.rg-„R,,,. ,,,trri•!'4,hr wc:. cip (�''..,4•• 41t. �':,++ a ,. ::: .o+.a I ,.�.�w.w.-, _.'. �•_•,
''.1::'':',1'...-W,.-Sonikcjr.,o..)• ''''..."•: . .- --s-..., � Y F ' aL - ..
The above sy,lc,t) Iitcp etrtt ' nrl•fotrtscf to-Cornply with plop Tncistics• • criplion: r4r fts a .' et''''-7•157'.7..t::..'
C 1^M1'Z`" Gam,__ 1 •'., :._ .f 1 k,. • Tam ...+.
�ysicn)s Conlroctor: _ r'� .<'i '•,l." •f `—r 'x4.: N1 ff'.,?' 4.-.R. •% tv.,, ,�µS: t.;., 1/4- • -
C(„� „e �,Q y • • : -,, •.:0010. • t: .. . • '- ' , ,,-��sry ;ire .-F7f'.
• Sanitation; ` •,� ��' ' .: .•:
F---iineer Review • • !` ": ` ,, �,
Ice;
q •ISigoatoreti:r.^., i; ,, }Permit ce p • �• � ^i•�r ^Sn:' -*t� �W r i ,-Th r
in ![11 1 •n , -� _ Iii*�.,,. ,„„;:,:i.,:Y' rte,•. k'°,y .i;: z-S>�
Received by; rve. '-t�vtX l Q �(!,� r t d'�. ,, r 1, u ,^4�
1516 F►f>spilof Rood •
Fr
- x. d k. .Grcc�lkrn alorndo i r'�.. �r -S.e� ,.....T.-:.:* .
/
y Ph 153;Q54Q x , fr ^'t , :w 4,i.zr ,' A
___ r'r tcopon far Permit to ,instoli, Construct,,,nn Indry u I pwa D ' ✓✓ff++K�q�,�,�y4yay,,�� -
'Y J�yJ i • • 4 r'trtiH'Y �
h�� i� 4 1-¢s �� 'F#te,'F .1 v i,�
y4 4+u+1reirY. nr v tI A 1i- " �•a l,@t,-v r' X ; .r
Direction t651te-: Hwy- Tm w d'�s�',Tr`` +�", ' ,�:-
sr N.h '-, kPr i i _r :'‘''."0:--4';4,71., ,'''','''!;':,,T,;('
y 'YJ...
Legal Description Ptx Sec ��µ��"""rrii�1�,, �( � �,�.°� „(, ,.�u q�,t'
4 ' l: Y w+ ��. N',,c.' " SUbi;t .. .t ! � .A.�n"7:-?:.
:- 75,4 +t.�t c
rs se.„...
- s w, .e„ +y' -r`^rn •-a;�.,✓F, +. a`�'< rev,• 1.''W. c,- '+M�w a A'^.
Gencru.) Inform`ot1anx xit i £�' 7 rt''e ? �, ,
No Bedroomr r] VI NO PcrsonssS , 4: 4 �y� « at, 111 ::::1;:::; .,_:$:-Et.,, ', ' �i W 1t
No Baths 'PS.r` ",,M.F >05.„,.:" "^ %Y�0,004 L~t9t a ri ,-4. . -4 './• t•i :"im {(�e,r "1;,
_._,. .B�Zcmc0t Plvmizin41,, `A ^t r�^ �# 'n ,�/*~r
Si•ie of lot' GZp" ` c "t ,,,,,,,,k,..‘,,,, ,,,,..,,,,,,,,,,,,"* kl a", ti 7�a��d?
f4,0 --- fi( -----give dePlh( • w Q '
New Home • Mobile Home-' Modular+4 '" r.4':' i .; 4 S J''
Add
Type pf sewage disposal regiestedr - - �k :41_ � til t 'r �i .4
SS/9 t it tank
tl!M Privy—�� Olher,. :. ,r ;:i '' .t` k�r: Y • _ e
rally' 111'5 l 77-n -1�1rote��r �' , .., "r C9n�ratc.t r h ;+.
g� -4 `7- -X"
IS OTItio i n ' D� of=l btrc,4 r- � t ,
r. *sv. ) s,Ixsi '..z .:' r u•rti cqu , 'r:.
a'i'l otwn�lnstructiops fMinimum Rc urrc c ''44 w -
_L Septic Tanta •�._...-/OOV '� s &t t z . 4Uv"ry„ 0�t.rv.Yr'4 n[� `f'.y`�4 ,F'y' .'? 5, ;+
5 ,. K.r r•H�'xt nr./ Sb{ar[71 CT •
Other 4:7: r
''v :: �"t� Lam' �
" --I' � der ' �`
Spc iol Instructions >✓�rt t, aA4.m�'s,'3 'M' „.$ 4+ ''"k'La e'yii h R
This t stecii wills i r ' wt „ ter.'
1 be ccir,clruclecl".nnrl installed icy actordonc� wish llre'aliovet S, C t , t� A''",'��t
gardtnq individual sCwbge disposal c slam :': s t 'T,,� _
� tt�-' County Colorodo� ci �_M
Ttiis,prrnvt shall e'q,ir•e of the smm�&Ii ie'os-,i r u lat a t.�Oqr �.. q l suj{ " v'shall'expire 1 day6'iafter 5th uauanS`s if;� uc 1',. �grR su. ,-.* fir '""-"" ;i'ti +' r7:'^„tv� �'i y4. -
h ,- �
�il m;�o'4.-� rs.
Bate .� . 4,x j r+ + n 'rZC( p 'f +a4 Yi�4r v dfo;11. Ir; r
f • : Gt i r ` r '�Spplieontrrr ..�. ,.w ' T .-
The plans nd specif'cations as shown `' ` - '",1 t $� ' -i M°-w_
o a avc
x.,; �s t� � d.pendrt� Aoy�?to�� per >� > .,_
a ��Y u
'3'y h L.
'Y +rr -Hry - YS q,"I ti„g T
.�4 n- eu 41-: � ;ail p ' J dhw».
The above system rnspc£Ied •nd totiiicl comply witttplon c r ct!c escnplion c44` f,
.. l T 1�f`i M - qL
�yStems Contractor is 3 U to F ° 6-1- ' irk
_
.' . (r V�rlgr.L& Di rw c- v :r ,4 +' SanitQCIQn fir' ' w an y
FeininecrReview;
�['�// 9:9 ca Ltt'",St: - gtgx •-.r=- 5515—, a:..,_
Permit Fee' $_N.J V +w # � , W r{ d i S 4 S s
Received b 4" S; '` + `" °
�,17S]IC u J air
�'"ii, fr W�4 .s.:§-`".. °» --,./' °, ria. '.
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