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--- SEPTIC INFORMATION FORM
‘8#(t'sTo obtain an I.S.D.S. permit, one must file an "Application for Individual
!,a ) , Sewage Disposal System" at the Weld County Environmental Protection
1 ' Services office,and pay the application fee. A"repair"fee shall be charged for
•5 •'' ' I • the expansion, replacement, or repair of an existing system. The following
information must be provided on the septic information form:
PARCEL NO.: /4161/146660 52 THIS CAN BE OBTAINED FROM THE
ASSESSOR'S OFFICE
, i
ATT(970) 353-3845 EXT 3650
/PROPERTY OWNER nvo LL C.,MAILING ADDRESS NTT E. 1?DO, 1'33nCITYTheirn/on SO
ST eDZIP 33
HOME PHONE (311 z -944. WORK PHONE (A3)sa3-3399FAx (a Dam'--4VV
APPLICANT NAME Qe�,en •)C?I�e p-s _
MAILINGADDRESS�99 E l&o 03So CITYThon, STC c D ZIP 56
HOME PHONE(%gzq-9q/&!o WORK PHONE Ba!sa all FAX f a64-1187
LEGAL DESCRIPTION PTT(s•4 PT/t',6•} SEC 0-7 TWN 1 RNG 67 ACRES ,11.3,
SUBDIVISION N/n- LOT BLOCK FILING
DESCRIPTION OF BUILDING (ex: House, Mobile Home, Modular, Shop,Office) AJ/t'
SITE/LOCATION ADDRESS 74, 010 W a g IDS F?. L i.6n, dot
DIRECTIONS TO SITE
NEW PERMIT X REPAIR PERMIT VAULT PERMIT
9315 $315 $150
IF OBTAINING A REPAIR PERMIT, PLEASE LIST PREVIOUS OWNERS OF THIS PROPERTY
FLOOD PLAIN YES/NO CENSUS TRACT
RESIDENTIAL YES/NO COMMERCIAL YES/NO
NUMBER OF PERSONS BASEMENT PLUMBING YES/NO
NUMBER OF BEDROOMS BATHROOMS: FULL 3/4 1/2
WATER SUPPLY: PUBLIC YES/ NO NAME PRIVATE
YES/ NO CISTERN YES/NO WELL YES/NO WELL PERMIT#
-4-
2004-0048
AUTHORIZATION FORM
RE: %SEPTIC PERMIT APPLICATION 0 I.S.D.S.EVALUATION
0 SALE// OF PROPERTY 0 WATER SAMPLE
1 iae4en Se rs represent / LL 6for the property located at
%we Like 1 D, FL. Lufl (/ .
LEGAL DESCRIPTION: . SEC 11 TWN ' I RNG C.0
SUBDIVISION NAME: LOT_BLK
I can be contacted at the following phone#'s: Home
spa- .b44vcio -
Work SD 3 'ga.'aslci • • ' •
•
Other p pr
Fax# 0406-05Q-We r7
The property owner can be contacted at the following phone f#s
Home Sain“ 40) ( nt
Work
Other
ax
OWNER'S SIGNATU dail ) DATE
!1`14 air it
-s-
/
'.rrrr . . OFFICE OF THE STATE ENGINEER
GWS-25 COLORAntennial DO DIVISION OFt., WATTE rado pRESOURCES
813
(303)866-3581- LIC
WELL PERMIT NUMBER 250881 -
DIV. 1 WD2 DES. BASIN MD
APPLICANT
APPROVED WELL LOCATION
ADAMS COUNTY
SE 1/4 NE 1/4 Section 17
HIS KINGDOM BUILDERS INC Township 1 N Range 67 W Sixth P.M.
3879 E 120TH AVE#330 DISTANCES FROM SECTION LINES
THORNTON,CO 80233- 2119 Ft.from North Section Line
942 Ft.from East Section Line
(303)254-9486 UTM COORDINATES
PERMIT TO CONSTRUCT A WELL Northing: Easting:
ISSUANCE OF THIS PERMIT DOES NOT CONFER A WATER RIGHT
CONDITIONS OF APPROVAL
1) This well shall be used in such a way as to cause no material injury to existing water rights. The issuance of this permit
does not assure the applicant that no Injury will occur to another vested water right or preclude another owner of a vested
water right from seeking relief in a civil court action.
2) The construction of this well shall be in compliance with the Water Well Construction Rules 2 CCR 402-2,unless
approval of a variance has been granted by the State Board of Examiners of Water Well Construction and Pump
Installation Contractors in accordance with Rule 18.
— 3) Apptgvad pursuant to CRS 37-92-6 1W1(A)as t1w only walione tract of land of 4040 acro$s)described es that
'- !motion ot*eSE4/4of.*e,.k&ld4r6ec4'7y4wWAdrl, agrfi '6iithP.M.:AdamsiCoNnib,tzoreparticulariydescribed
on the attached exhibit A.
4) The use of ground water from this well Is limited to fire protection.,ordinary household purposes inside not more than
three(3)single family dwellings,the watering of poultry,domestic animals and livestock on a farm or ranch and the
irrigation of not more than one(1)acre of home gardens and lawns.
5) The total depth of the well shall not exceed 800 feet,which corresponds to the base of the Laramie Fox Hills aquifer. At
a minimum,plain casing shall be installed and grouted through all unconsolidated materials and shall extend a
minimum of ten feet into the bedrock formation to prevent production from other zones.
6) The depth to the top of the Laramie-Fox Hills aquifer is approximate. To ensure the exclusion of poor quality water from
zones Immediately above the aquifer,plain casing and grout shall extend through the lowermost coal and/or
carbonaceous shale that overlies the Laramie sand portion of the aquifer.
7) The maximum pumping rate of this well shall not exceed 15 GPM.
8) The return flow from the use of this well must be through an individual waste water disposal system of the
non-evaporative type where the water is returned to the same stream system in which the well is located.
9) This well shall be constructed not more than 200 feet from the location specified on this permit.
NOTE:To ensure a maximum productive life of this well, perforated casing should be set through the entire producing
interval of the approved zone or aquifer indicated above.
NOTICE:This permit has been approved with a change to the permit application form from that applied for by the
applicant. You are hereby notified that you have the right to appeal the issuance of this permit,by filing a written request
t It(V'eeiftf iniffiffifiblf(INI)tlepPeribettlehessfissuance uanbta.theStateAdministratiaP.roceduresAgt4$ee .
Section 24-4-104 through 106,C.R.S.) P _.. 6 f(0103
APPROVED
JLV ��ll L
State EngIneer By
Receipt No.0509187 DATE ISSUED 06-06-2003 EXPIRATION DATE 06-06-2005
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