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Home My WebLink About20041805.tiff ..-., j WRJ-5-66 • STATE OF COLORADO ge kErTIF� !I A PERMIT TO USE GROUND WATER L55 APPLICATION FOR: A PERMIT TO CONSTRUCT A WELL SEP 22 1966 L/ OTHER Application must be completed satisfactorily before acceptance 'ROUND WATpp SEC1 lt) . PRINT OR TYPE LOCATION OF WELL $f4 APPLICANT Clifford Davis,. Jr. COUNTY Weld Street Address Star Route SW :* . - SE *, sec, 17 City & State Hudson, Colorado 80611.2 T. iN , R. 65w , 6 P.M. Use of ground water domestic Ground Water Basin Owner of land on which well Water Management is located Clifford Davis, Jr. District Number of acres to be irrigated USE:-DIAGRAM MN .THE BACK.OF THIS SHEET TO Legal description of LOCATE WELL. irrigated land Other water rights on this land Driller golden 4 Holden No. 1 Owner of irrigated Driller's land Address - P.. 0. Box 188, Hudson,, Colo. Aquifer(s) ground water is to be obtained from ESTIMATED WELL DATA �� igne re or Appli'' ant Est. quantity of ground water to be claimed: - CONOTTBONS•-OF=-APPROVAL Est. Max. Yield PO GPM or CFS Est. average annual amount to be used in acre-feet Storage capacity AF Anticipated start of drilling 9/21 19 66 Hole Diameter: 9 ' In. from 0 ft. to 60 ft. in. from ft. to - ft. Casing: .. Plain 5 9/18n. from 0 ft. to la ft. in. from ft. to ft. Perf:-5* in. fran _ft. to 6©` -ft. in. from ft. to-. ft. PUMP DATA: Outlet Type unknown HP Size This application approved: . This:appiicat;ionapproved- PERMIT NUMBER 28908 CONDITIONAL PERMIT NO. . (Permit ,goo4„fee ote A1 ) ,year,.a ter date DATE ISSUED S 2 3 ', 66 of Issuance) DATE ISSUED State Engf➢y.'ri � /J !(/�/p Chairman Ground Water=Goromission by by (OVER) ','i ' -: 2004-1805 APR 4 1967 -•. 1 WRJ-25-66 STATE OF COLORADO �° 20-m-45DIVISION OF WATER RESOURCES ,fi Index No. �'�a:� � OFFICE OF THE STATE ENGINEER O� .IDWD Use / MAP AND STATEMENT FOR WATER WELL FILING D , �B6'' Registered/it'd/3146; •..A.',; PERMIT r ;;= jra lift l% NUMBER 28908 Know all men by these resents: That the undersigned 03 if:ravel Dairy i 1 , claimant(s), whose address is , City , states: Claimant(s) is (are) the owner(s) of well No. 289o8 located as shown on the map below; the total number of acres of land owned by him (them) to be irrigated from this well is :;; ; work was commenced on this well by actual construction 22 day of Reptetnhri i O a?9h; the tested capacity of said;well is 8 (gpm) (cfs), for which claim is hereby made far do>nestit purposes; that the average annual amount of water to be diverted is acre-ft. andthat,tlfe aforementioned statementsuare made:arid this map and State nt are filed in compIiance with the laws S State of Colorado C-� t' County of ) Claimant(s) Subscribed.and sworn before me this , day of , 19 My Gomission.:expires._ ' ' Notary Public MAP THE WELL SHALL BE LOCATED WITH REFERENCE TO GOVERNMENT SURVEY CORNERS OR MONUMENTS, OR SECTION LINES BY DISTANCE AND BEARING. •• - t feet from (North or South) section line , feet from ^ (East or West) section line IF WELL IS FOR I THGATION,' THE AREA TO BE IRRIGATED MUST BE SHADED OR CROSS- HATCHED. r;.r> , The square below will be used to indicate the location of the well`and the irrigated land. I l- Iill ,(t -i't:' I i I. - - T ill WELL LOCATION T - V T I I I I �. I .., _-. y� ,---44" _ _ I 0.4. . , County I I I • • I 1 I r �: .: .. fly 114 RR 1/4, sec n : 17 - - - T - -F - - r r - - r - - T. 3A R, It .f1�1d 6 P.-M. I 1. I ... `wo.f,oT.i , i,„. ,. .• ... :, .•4,l-- . i Ground_NSer(B;isitl , , 1 I _ :,,,i 1 1 , h Water I�Ianttglement 1 •. I I I 1 I 1 . ;' , ,: DistrictI I , 'lc i c`,; ;:3 “*.1-L,.:__ Domestic wells may be located by the -_ _J.__I.__L__, S_-£1_44.+:1..-r:.-,z 1mi. following: LOT , BLOCK SIIBD,W SIGN I 1 I I I I I i 'I i.. ACCEPTED FOR. FILING.IN..TH.E..OFFICE-O,F..THE.STATE...ENG1N.EER.-OF .COLORADO-ON-MIS- •; DAY OF State Engineer z 1 LOG AND HISTORY • WELL,LOG WELL DATA,- : - Ground Elevation Date Started September 22, 1966 Type DrillMa-,' , Retarp Date Completed SeptemS Water Hole Diameter: From To •1 iTytpeiof&Matefial i ` ' '+ Loc. Perf. q 'in. from 0 ft. to 50 ft _in. from ft.'to ft. in. from ft. to ft. 0 !a. sand 9 clap., ,. . CASING RECORD 9 7 a ' and Cemented from gravel ,pack 14 27 clay Plain Casing 27 31' :. gravel a s Siz /,iiid'atealrorit' L ft. to , ft. 31 144 clay a 44 50 shale Size_, kind_from_ft..to ft. Size_, kind_from—ft. to ft. Perforated Casing Sizes, kindSttuarom lit. to. 50. ft. Size—, kind_from_ ft. to ft. Size._, kind_from_ft. .p;— ft. ft. TEST DATA Date Tested Se tember 22, 1966 Type of Pump bailed Length of Test 2 hours • Constant Yield ,B, G M: Drawdown 23t PUMP DATA (To be filled in) Type of Pump nnlrnnwn Outlet Size ' Driven by, . . rr Horsepower Use additional paper it necessary3Lbcimplete log and attach. DEPTH 10 uas ldi., . 87► Wi LL DRILLERS STATEMENT--r-1 State of Colorado ) °f.a County of Weld ' �, H ). EIS Yi.C B. j,. Holden being duly sworn, deposes and says: he is the driller of the ab'bve''debcrili'ed"well, he hat-read-the•'above map and statement, knows the content thereof, and the sanie'is'trife''di"hi'sl knov4ledge. Holden & Hel en License No. :1 Stihecribed and sworn to before me this 29 day of September , 19A6. My Commission expires Mao 2 , 19_1.9 _ L 2 /".Q 9. Notary Public OEM TO BE MADE OUT IN QUADRUPLICATFa - s Original WHITE (both sides)&Triplicate GREEN Copy must be filed with the State Engineer within 30-days after well is completed. Duplicate PINK copy is for the Owner L YELLOW copy for the Driller. WHITE FORM MUST BE AN ORIGINAL COPY ON BOTH SIDES AND SIGNED:- _. . ..... - - • . �-- THE LOCATION OF THE PROPOSED WELL SHALL BE SHOWN ON THE DIAGRAM BELOW. THE LOCATION WILL BE INDICATED BY THE DISTANCES FROM THE SECTION LINES, OR THE DISTANCE AND BEAR- .-. ING FROM GOVERNMENT SURVEY CORNERS OR MONUMENTS. IF WELL IS FOR IRRIGATION, THE AREA TO BE IRRIGATED MUST BE SHADED OR CROSS-HATCHED. Domestic wells may be located by the following: Lot 17 & 18 Block Vantage Acres Street Address o. 1 or City Hudson, Colorado Subdivision The diagram represents nine (9) sections. Use the center square (section) to indicate the location of the well . ti THE SCALE OF THE DIAGRAM IS TWO INCHES EQUALS ONE-MILE \P , /\ V: '41 *Hog DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT 1555 N. 17TH AVENUE GREELEY,COLORADO 80631 ADMINISTRATION(970)304-6410 PUBLIC HEALTH EDUCATION AND NURSING(970)304-6420 FAX(970)304-6415 Wiggle ENVIRONMENTAL HEALTH SERVICES(970)304-6415 FAX(970)304-6411 COLORADO AUTHORIZATION FORM RE: O PERMIT APPLICATION S.D.S.KI. EVALUATION ❑ SALE OF PROPERTY ❑ WATER SAMPLE '> jot 4 !bum UDIL)b}fa iKii represent I W ln r7._ .1 I for the property located at NK • . IJII LEGAL DESCRIPTION: SEC I 7 TWN I RNG(051,0 SUBDIVISION NAME: \I(LIl_ 7 C kJ . LOT 17BLK / ' I can be contacted at the following phone #'s: Home :363— 5 lP'-q/45 WorkCt)3- 11po%-4/6;3. Othe3 [ /J&? Fax# The property owner can be contacted at the following phone #''ss � Home\3 3 �/y-4O ) Work 6 O- p�?& 4773 Other e� n0 Fax # OWNER'S SIGNATURE GrL CLh A�Y[4_u DATE t-ca:;- OY N 3 COUNTY DEPARTMENT OF PUBLIC SOE# HEALTH AND ENVIRONMENT ORG PERMIT # 1555 N. 17T"AVENUE REPAIR# GREELEY, COLORADO 80631 LOAN # 1111 It PHONE: (970)304-6415 ISDS # FAX: (970) 304-6411 STATEMENT OF EXISTING FOR SEPTIC SYSTEM COLORADO ifj�t y' (PLEASE FILL OUT IN BLACK INK ONLY) PARCEL NO. 1415 14 o a3 PROPERTY OWNER V#'iL . PHON NO. al, 2S-g773 MAILING ADDRESS City State Zip DESCRIPTION OF BUILDING(ex. //house, mobile/modular^d �honme,shop,office) /1/+� SITE/LOCATION ADDRESS 3I UI f \104#Cg 'f-•` `# ✓ FLIP ccccJJJJ City State rZip LEGAL DESCRIMON-y_ PT PT SECTION( 1 TOWNSHIP f, N RANGE LAW SUBDIVISION V&Ate reS, LOT /1 BLOCK FILING CENCUS TRACT pf LOT SIZE/ACRES 4.5.7C COMMERCIAL YES NO RESIDENTIAL ES ' O NUMBER OF PE SONS BASEMENT PLUM :ING /NO BEDROOMS PE B; ROOMS -FULL 3/4 1/2 WATER SUPPLY - PUBLIC _ / NA PRIVATE E 0 WELL E O CISTERN YE O WELL/CISTERN# 1y4' SYSTEM SIZE: Septic tank material is constructed of Glen'it and has / av) gallons a acity. FIELD: Trench square feet or Bed I 6 (JO square feet YEAR INSTALLED 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. The undersigned property owner hereby certifies that the above described septic system is in fact installed,as described, and a fists at this time on the parcel of ground identified by the above legal description and further states that the system Ws not in good working order and to the best of his/her knowledge is s no ailing to function properly. I further understand that any falsification or misrepresentation may result in revocation of any permit granted based upon this information hereby submitted and in legal action for perjury as provided by law. 1 -19- c4 ' )r r (0 e, 1.t )jn .ecstic. DATE OWNER Subscribed and sworn to before me this I Ci Cal" day of '\^:O,'1`1 U4) -, 20 O 4/ VI By T> ot\c11k Op : 01111e,,,.;:ski Witness my hand and official seal. My commission expires( is Y - C. �7 /- 14l -8 '1 A _ q &c (Li3L , DATE NOTPUIBLIC STATEMENT OF EXISTING REVIEWED BY . ENVIRONMENTAL HEALTH SPECIALIST 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 01-23-2004 Payment Method: Check Notation: 553 Initials: MS ISDS EVALUATION NO:ISDS-04007 Receipt Number: ISDS-0007 Donald J.Wroblewski Location: 3161 VANTAGE DR HUDSON Account Code Description Amount 2560-41400-4410-4203 ISDS Evaluation S100.00 Description of Building: Current Flow Additions Proposed Total Desc HOUSE RE HOUSE Persons 3 0 3 Bedrooms 2 0 2 Bathrooms 1 0 1 Bacot Plumb Y Y Water Source: PWELL 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 WeW County Department of Public Health and Environment in evaluating the same for purposes of septic systems compliance. I further understand that any falsification or misrepresentation may result in the denial or revocation of any evaluation granted band upon said evaluation and in legal action of perjury as provided by law. X )/414 Owner/Applicant ate Form:RT_ISDS WELD COUNTY DEPARTMENT OF PUBLIC HEALTH 6c ENVIRONMENT • 1555 NORTH 17TH AVENUE, GREELEY, CO 80631 PHONE (970) 3046410 FAX (970) 304-6411 STATEMENT OF EXISTING RECEIPT Receipt Number: HES-04006 Amount: $10.00 Date: 01-23-2004 Payment Method: Check Notation: 553 Initials: MS Owner Name: WROBLEWSKI DONALD J Applicant Name: WROBLEWSKI JOE&TAMMY Permit Number: SE-0400007 Parcel Number: 147317402003 Site Address: VA-17 L17 VANTAGE AC RES #1 %3161 VANTAGE DR% Location: 3161 VANTAGE DR VAN Total Fees: $10.00 Total All Payments: 10.00 This Payment: S10.00 Balance: $0.00 Account Code Description Amount 256041400-4221-400 Statement of Existing $10.00 RT_HEST Hello