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2001-0513
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3E.-- _L9i0 99:5c F. :I.
W 7)COUNTY DEPARTMENT OF PUBLIC SE # ,annnnoS
6 Hi _TH AND ENVIRONMENT ORG PERMIT#
fir 1556 N. 17Th AVENUE REPAIR#
GRBEJ.EY, COLORADO 80631 LOAN#
PHONE: (970)304415 ISDS#
I ) FAX: (970)304-6411
1 Q
STATEMENT OF EXISTING FOR SEPTIC SYSTEM
(PLEASE FILL OUT IN BLACK LNK ONLY)
PARC IA /4/ /073SC) 000 32-
PROP"TY OWNER(il/. Ito ref -•-•(ro 4, i nv.,* l frt ,k,i PHONE NO. Rfal ..- 5,;;;I -f,t/r
L..este c. P,' xt nj
MATL t 'G ADDRESS v/ e eO C,t_ /e CJ'a C o eaS/(v
City State Zip
DES ION OF BUILDING(ex. house,mobile/modular home,shop,office) k-t on se.
SITE, OCATION ADDRESS_ J-/-7 is C g.. a Erler (I) Wt7 Jo
Ci State Zip
LEG DESCRIPTION PT S l; IT kith SECTION 3£ TOWNSHIP 1 N RANGE W
S !VISION LOT BLOCK,^ FILING_
CV{ TRACT LOT SIZE/ACRES LO 3
CO RCL#L RESIDENTIAL N ,�� �
ER OF PERSONS BASEME LUMBING YES i r
BF ) OMS_3_. BATHROOMS FULL 3/4 I/2_74_1
/
WA R SUPPLY PUBLIC UTILITY NAME1'7l y 1 Cw UJ/l!e l �'*'r5
PRIV TE YES 19 CISTEp r WELL S/ WELL PERMIT#)
SYSTEM SIZE: Septic tank material is constructed of�.Lrj�.and has E/ QOO _gallons capacity.
FIELB: Trench ft 500 square feet or Bed square feet Y AR INSTALLED /4 /o n
i
Yon a e required to draw a diagram of the system on the reverse side of this form in black ink only and indicate
locatida,length,width,and distance from the dwelling.
Then dersigned property owner hereby certifies that the above described septic system is In fact installed,as
deac ' ,and exists at this time on the parcel of ground identified by the above legal descriptioa and further states
that e system is/in not in good working order and to the best of his/her imowledge Islis nog failing to function
praise ly.
I fun er understand that any falsification or misrepresentation may result in revocation of any permit granted based
upon his information hereby submitted and in legal action for perjury as provided by law. 1K"J�5170..fr•i (97fi IT dylitai A.ti-4)DATi OWNED
I/
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Subscribed and swam to before this day of .J,'v . , l99.x" I'
by ,A,i2.4'Q 61f-- / /i.'/'C% / /-S/. .G. •- %, 4"E' t: ';y:
/ My commission-expires ;
wttnees my hand and official seal.
NOTA PUBLIC y
- S C.' Xk yl ' �. �.
7
DATE 1 e r
STATEMENT OF EXISTING REVIEWED BY
ENVIRONMENTAL PROTECTION SPECIALIST
EXHIBIT TOTAL P.02
I ay
SE?-27-2033 2S'52 G'
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