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\ DEPARTMENT OF HEALTH
1517 16TH GREELEY, CO 80631
livgive ADMINISTRATION (970) 353-0586
HEALTH PROTECTION (970) 353-0635
.COMMUNITY HEALTH(970) 353-0639 353-0639
COLORADO
February 5, 1999
Ronald R. and Michelle L. Sack
24545 Highway 54
Hudson, Colorado 80642
RE: Ronald R and Michelle L. Sack ISDS No.: 99-010
Septic Permit No.;SE-9900019
Dear Mr. and Mrs. Sack:
On February 1, 1999 an evaluation of the existing individual septic disposal system at
24545 Highway 52 Hudson, Colorado; Section 06, Township 01North, Range 64 West,
was conducted by Pam Smith.
The existing individual septic disposal system is of sufficient size and capacity to
adequately handle the proposed load. This evaluation is based on a final treatment
capacity for a�_bedroom residence.
Be advised, neither the County of Weld nor any of its agents or employees undertake or
assume any liability to the owner of the above property,to any purchaser of the above
property or to any lending agency making a loan on the above property or in the report.
This inspection was'conducted for the purpose of determining compliance with current
regulations and for detecting health hazards observable at the time of inspection. This
does not constitute a warranty that the system is without flaw or that it will continue to
function in the future. Inspections requested during periods of snow cover and high soil
saturation may be of questionable value to potential buyers due to adverse conditions.
Evaluations based on Statements of Existing(S.O.E.) relies on yy information the property
the best of h s/her knowledge the system current
s not failing tfo the
properllyePresenting to
If we can be of any further assistance, please contact our office at 353-0635.
Sincerely,
Set
Environmental Protection Specialist
PS/rb-0115
Enclosure (1)
cc: Weld County Planning Department
2003-0139
10;03/02 12:00_ FAl 970 304 69x8 WELD PLANNING �•.. G.��. 004
."wo"w,. WEL' OUNTY HEALTH DEPARTMENT SE* q 9 it°1
att • ENVImaNMENTAL PROTECTION SERVICES ORG PERMIT*
1517 16TH AVENUE COURT REPAIR IS
GREELEY,COLORADO 80631 LOAN*
See.&Ny.POI PHONE: (970)353-0635 'SOS*
FAX: (970)358.4966
STATEMENT OF EXISTING FOR SEPTIC SYSTEM
(PLEASE FILL 'OUT IN BLACK INK O Y)
PARCEL*
PROPERTY OWNEIC?otw.ld 'rcrlcha.1e ci PRONE NO. (3O3 1 S-N.0.Div 4t)
MAILING ADDRESS 2'CMIS Ato Co ln&..
City State Zip
DESCRIPTION OF BUILDING(ex. house,mobile/modular home,shop,office)
SITE/LOCATION ADDRESS
City State Zip
LEGAL DESCRIPTION PtS +'��PT5E'(4 SECTION Ls TOWNSBIP__ RANGE.kii3O
SUBDIVISION LOT_ _ BLOCK FILING
CENCUS TRACT LOT SIZE/ACRES J
COMMERCIAL_Yaqi;) RESIDENTIAL!NO
NUMBER OF PERSON BASEMENT BASEMENT PLUMBINQ_NO
BEDROOMS 4' BATHROOMS FULL_ 3/4 1!2_1 _
WATER SUPPLY PUBLIC YE UTILITY NAME U,u.±ad
PRIVATE NQ_ CISTERN_Y lL O WELISJ NO WELL PERMIT
-
SYSTEM SIZE: Septic tank material Is constructed of ('ztic.iz.fc_and has /51t X 2 _gallons capaci
FIELD: Trench square feet or Bed 3GoO square feet YEAR INSTALLED 1 ' 'X.
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 exists at this time on the parcel of ground Identified by the above legal description aad further states
that the system is/is not in good working order and to the best of his/her knowledge jy/is not failing 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.
//,20/9`1 / ' EL L.t& . eJWk
-
DA'TE OWNER
Subscribed and sworn to before me this ;U day of ) 1 _, 1993_,
by —
Witness my baud and official seal. My mission expires: /I- f 1' a no/
/_ .)n. 9 9 /c�n��✓D - -
DATE NOTARY PUBLIC
STATEMENT OF EXISTING REVIEWED BY_
ENVIRONMENTAL PROTECTION SPECIALIST
O
,
(Rev.)
;* STATE OF COLORADO
DIVISION OF WA'T'ER RESOURCES
OFFICE OF 'I'IIE STATE ENGINEER
GROUND WATER ADMINISTRATION
PERMIT
NOTE: This permit is issued for the purposes
indicated in the application.
iii) 111; Titili\ViiEH
Form C Rev. t STATE OF COLORADO '
9-62/1OM A PERMIT TO USE GROUND WATER li 011 '} 19:Y73
APPLICATION F'OR: A PERMIT TO CONSTRUCT A WELL GROUND W.STER S°i
r - Applicant 1./..0 m.);,. i.nAy,;�L LOCATION OF WELL 0 LORAl!0
Address
/ ( ;iu`.i f_h l:0 arty `r STMT C.Iet3!Y•c i;
P. O. Address,74,,,�j-e,t . _J%a, _..4.,,Lb, ` 1 /
Quantity applied for ,Z(? gpm or Slf, ;; u15./: 4 of Sect. ,,, , Twp. /"Le,
AF Storage /
1. Rge. 4,j/ fy ( !.-r. P. M. OR
• Used for ,/-.-2-"v 2%.^ Purposes
1-2.7ys- '
on/at t° Street Address or Lot t: Block No.
(legal description of land site) '-'j
s.o Town or Subdivision
_otal acreage irrigated and other rts. °
• ESTIMATED DATA OF WELL w ° N
4
Hole size: j in. tq-c Cif,ft. x N I ' �s
in. to ft. i tis
ed i Y
LT --
Casing Plain in. from/2 to/Tirt. 3°`' i I Locate
in. from to ft. a, I well in
• Open or Perim( in. fr<im�' s2 C tO ft. E W 40 acre
in. from to ft. 'E m I (small)
•
PUMP Outlet �, w ' I square
DATA: Type. t -�. IP/ „Size -1ze o ° I _ - as near
zM - - - ' -- - as possible.
Use initiation date 74'17, �S9y ❑ , I Large Square
(Use Supplemental pages for additional data) :1 j i 1 is one section.
6' 3 S
$25. 00 fee required for uses other
THIS APPLICATION APPROVED than Domestic or livestock.
:- PERMIT NO. • 18033 Applicant •
ISSUED: Agent or Cr.'
HATE NOV 14 1963 19_ Driller. J � ',,. .c '?.,,,4i,,,, ., No. �'
Address________________________
"OTE - SATISFACTORY COMPLETION REQUIRED FOR APPROVAL OF APPLICATION
THE ABOVE APPLICATION, BEING A PART OF TFils PERMIT, IS APPROVED AS
INDICATED.
y AA_ �r �r ,h
&A- — `iI'A I 1 Irp1C,1411.ER
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