HomeMy WebLinkAbout20020011.tiff Q. ai.sa
Agreement for Water Main Extensions
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This agreement,made and entered into this day of M 1,/ �7,by and between LITTLE
THOMPSON WATER DISTRICT,hereinafter called the"District"and / NEo D oRLL n JC,7'gc C'
hereinafter called "Customer", is upon the following terms and conditions, to-wit:
1. The District is organized as a special district under laws of the State of Colorado serving treated water within the District as may now be
established,or as hereinafter established.The Customer is either a taxpaying elector within the District,or desires to receive water service
and to join the District.
2. The Customer desires to obtain water service for the "property" described in this Agreement.
3. The Customer shall pay for and provide all water mains either within or without the boundaries of the District in order to provide
water service to the property; but the District may construct said mains,or the District may approve construction by the Customer,or the
Customer's contractor upon terms approved by the District.
A. The District must approve such construction by the Customer,or the Customer's contractor by a written agreement providing for
the terms of such installation, including requirements that the materials used shall meet all standards of the District and that
provides for inspection by the District of the construction of such water mains.The cost of all construction shall be paid by the
Customer to the District.
B. A deposit in the amount hereinafter provided shall be paid by the Customer to the District as an advance towards the construction
cost of the District for such installation.After completion of all construction and acceptance by the District,a final adjustment of
costs will be made, if necessary. In the event that it is determined that the deposit is insufficient to cover the estimated cost of
construction, then the Customer shall pay to the District, on demand, additional advances towards the cost of construction.
C. If the installation is constructed by the Customer, or the Customer's contractor, the Customer shall transfer all right, title and
interest in and to the facilities installed as well as all easements and appurtenances and other necessary property rights to the
District by good and sufficient assignment or bill of sale or general warranty deed.Such transfer shall be made free and clear of all
liens and encumbrances, and the Customer shall furnish sufficient evidence of title or a"form 100"title policy if required by the
District.The Customer shall furnish mechanic's lien releases or a good and sufficient performance and payment bond pursuant to
the Colorado Mechanic's Lien Law in order to insure that all construction costs have been paid in full. All labor and materials
shall be warranted for defects of any kind by Customer and Customer's contractor for one year from the date of acceptance of such
facilities by the written acceptance of such facilities.The District,upon receipt of the documents of transfer and evidence of title,
shall consider whether to accept or reject the installation. If the Customer has complied with this Agreement and all other
• conditions precedent to the acceptance of the facilities, the District shall approve and accept the transfer and shall thereafter
assume operation and maintenance of the lines.In no event shall the District assume ownership,operation or maintenance of any
installation on the service side of the metering installation for the property.
4. The District will provide service in accordance with its rules and regulations and line extension policies as now adopted or as may be
hereafter adopted by the District.The Customer shall commence payment of established rates of the District,including minimum fees,on
the date of installation of a tap and water is available for use at the tap.
5. The District, pursuant to the terms of this Agreement, will only be obligated to serve the tap size shown on this Agreement.
6. The terms of this Agreement shall apply to the property described herein,and the taps hereinafter provided may be used only upon said
property. The parties hereto agree that this Agreement shall be treated as personal property and not real property.
7. The Customer shall provide the District with an accurate copy of the final plat of the property to be served by the District.If the plat
must be approved by the County Commissioners,then a recorded copy of the plat with the Clerk and Recorder of the Colorado County in
which the development is situated must be provided to the District.
8. Customer hereby grants to the District the right to enter upon the land of the Customer and on the property as herein described to
construct,operate and maintain the facilities herein described, together with the full right of ingress and egress,and to cut and trim trees
and shrubbery to the extent necessary.The Customer shall obtain and convey to the District all easements required by the District,and the
District shall not be responsible for any delay in providing service in the event of failure to provide such easements.Furthermore,failure to
provide easements required by the District will cause this Agreement to become null and void and of no further force and effect,and the
Customer shall forfeit all money or rights theretofore transferred to the District. .
9. The facilities herein described are required by the Customer by date hereinafter stated.In the event the District installs the facility,the
District shall use reasonable diligence in providing said facilities by that date. If said facilities cannot be installed because of act of God,
governmental authority, action of the elements, accident, strikes, labor trouble, inability to secure materials or equipment,or any cause
beyond the reasonable control of the District, the District shall not be liable therefore or for damages caused thereby.
10. In the event the District installs the facilities, the District shall install the facilities described herein in accordance with good
engineering practice after the Customer has established property lines, cut streets, alleys and easements to final grade and prior to the
paving of streets, and the construction of curbs and gutters.The Customer shall reimburse the District for any expense due to subsequent
changes by the Customer.
II. Water service shall be provided to Customers located within the property at the District's applicable rates, and upon terms and
conditions now in effect or at the rates and under the terms and conditions as may be hereafter be adopted by the District and upon the rules
^and regulations as now established or as may hereafter be established by the District.No water service may be obtained except upon property
icluded within the boundaries of the District. Customer agrees that no other person shall be permitted to use water provided by the taps
nerein described.
12. In the event that construction of the water mains is not completed by the Customer or the Customer's contractor on or before 2 years
from the date of this Agreement,then this Agreement shall become null and void.In such event,the District may setoff against thedeposit
herein provided for the amount of its expense and return the balance of such deposit, if any,to the Customer.Customer agrees to pay all
expense incurred by the District in excess of such deposit.
LTWD FORM 210
(Rev.May 86) Page 1 of 2 2002-001
- i1.1,
Agreement for Water Main Extensions
13. (Delete if inapplicable.)In order to off set the cost of water to supply the property herein described,the Customer agrees to sell to the
district the number of acre-foot-units of the Northern Colorado Water Conservancy District, Loveland, Colorado, water rights at the
.mount for each unit,hereinafter described.Customer shall not receive cash for such units transferred to the District,but the total value of
such units as herein stated shall be applied to the tap price established by the District upon the date of installation of each such tap.
14. The District agrees to allow installation of the number of taps hereinafter provided within the above-described property,and each tap
shall not exceed 3/4 inches.No taps will be served by the District until all of the terms and conditions of this Agreement have been fulfilled
by the Customer,including transfer of the above-described water rights.The taps may not be used on any property other than that described
herein without the express prior written consent of the District to such transfer.Any such transfer shall be made to property owned by the
Customer, and such property, and the Customer, shall meet all rules,regulations and requirements of the District in order to achieve a
requested transfer. Any right to receive a tap option or water rights credit under this Agreement, whether upon the above-described
property,or at any other place shall expire and become null and void 20 years from the date of this Agreement.Customer may not encumber,
mortgage or collaterally assign the taps without the prior written consent of the District thereto.In all other respects the taps or water rights
credit shall be treated as personal property.
15. Because installation of certain facilities to the below described property may benefit property owned by other Customers of the
District, the District may pay tap rebates to the Customer upon receipt of a fully paid tap fee from another party to serve property not
included within the below described property.These tap rebates will be paid in accordance with the District Rules and Regulations and the
Customer should familiarize themselves with this portion of the aforementioned Rules and Regulations. The parties hereto agree that
refunds will be made for a period of 5 years from the date of this Agreement and that upon expiration of said 5 year period,the District shall
have no further obligation to make refunds.The total amount of the tap rebates will not exceed the Customer's cost for the improvements.
16. The Customer agrees to abide by all rates established and rules and regulations of the District as now established or as may hereafter
be established by the District.District shall not be liable for any injury or damage for failure to deliver water for any reason including but not
limited to war, riot, insurrection, Act of God, or breaks or failure of the water system.
17. No agent or representative of the District has the power to amend, modify, alter or waive any provisions of this Agreement. Any
promises, agreements, or representations made by any agent or representative of the District not herein set forth shall be void and of no
further force and effect.
18. The Customer understands and agrees that all amounts due under the terms of this Agreement, as well as all fees, rates, tolls,
penalties, or charges for services, programs, or facilities furnished by the District constitute a perpetual lien on the property herein
described,and that such lien may be foreclosed in the same manner as provided by the laws of the State of Colorado for the foreclosure of
mechanic's liens.§32-1-1001(1)(j),C.R.S. 1973(1981 amendments).In the event Customer fails to abide by any of the terms or conditions of
,.-'his Agreement, Customer agrees to pay all costs and expenses incurred by the District as a result of the breach including direct and
msequential damages, loss of revenue, attorney fees, court costs, expert witness fees and other expenses.
19. This Agreement shall be binding upon and inure to the benefit of the heirs,personal representatives,successors and assigns of the
parties hereto. Except as provided herein, the Customer may not assign all or any part of any interest in this Agreement to any person.
IN WITNESS WHEREOF, the parties hereto have set their signatures the day and year first above written.
LITTLE THOMPSON WATER DISTRICT ,/ ,% //, ��CUCSST/VMER ////�
By: BY G�ff��!-�•"`9„mseTJ(! ---��}W-- [ � ' �
iling Address: 5G,J -' << �,C&/ - , /C9
Ratified by LTWD Board of Directors on: - /C . l ",e7• //8;55,37/
ele one: 9 70 — h 9-!a 3-6
I) Real Estate Description for Agreement("property"):
gr; - z '5-09 PnrZ.ON aF Noki G - 4 -6s
WbkP canny
2) Amount of Deposit: $ N
3) Date Customer needs facilities: 'et-
4) _44_
//
Number of Northern Colorado Water Conservancy District units transferred to District: .
5) Price per unit of Northern Colorado Water Conservancy District water: N'A
6) Tap Size: 5/8 x 3/4 inches.
/"Number of taps to be installed: I
D.tsncscr W.Ytc flt/Wczon 6 42 .ca/`T
8) Plat Provided? X Yes No Of *h/. '3 Sao / ,,
I L iv,E
9) Number of new fire hydrants: P4 7C
10) Fee for hydrants: $ Zof7O •
LTWD FORM 210
(Rev.May 86) Page 2 of 2
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PROJECT NO.: NH 2873-068, Unit 1
PROJECT CODE: 11354
ITEM NO.: Water Tap# 1461 -
CLOSING STATEMENT
FOR DISPOSAL OF PROPERTY
I, the undersigned, do hereby certify that on this date full payment was received from the
Theodore H. Schrage, for a Bill Of Sale for a Little Thompson Water District water tap # 1461
formerly located at 100 Sunset Court,Loveland, CO 80537 of the State of Colorado, Department of
Transportation, Project No. NH 2873-068, Unit 1. I also acknowledge receipt of the ollowing
amounts as payment for this property in certified funds.
Sales Price of Property: $11,600.00 ^ C
alb
Less Deposit Received: 1,000.00 it< V(-
Recording Fee: None OtEti
Documentary Fee: None X/
Other:
Total: $10,600.00
DATE:j21 3 100 STATE OF COLORADO
DEPAI�TNITIM `i lNTAW GTRANSPORTATION
BY: ! ✓
Richard Barker
I, the undersigned,acknowledge receipt of a copy of the Bill Of Sale for a Little Thompson
Water District water tap# 1461 formerly located at 100 Sunset Court,Loveland, CO 80537 and part
of the State of Colorado,Department of Transportation,Project No.NH 2873-068,Unit I `g� �
4.0
DATE: b U (
: Theodore H. Schrage
cc: Staff Right of Way
Rev. 2/95 CDOT Form#255a
BILL OF SALE AGREEMENT
The undersigned hereby formally transfers and assigns to the Little Thompson Water District all
rights of ownership of the water line pursuant to that certain Agreement for Water Main
Extension between these parties dated 0 Mn y 4_9.zacc
Grantor warrants that all subject improvements are free and clear of liens and encumbrances. The
water line improvements were installed at the following location:
Property Address: \A/ ( L. 3 5-o..,,77-/ 6r i4 w r C
Section Township North, Range West of the
6th p.m.
The water line improvements are more specifially described as follows:
-7; 44 (s C-900 water line installed
with Bate valves d- (f/Uf'--tV7
1 7kvD Lua cv run: cn i OF P/8,6,0/k F1A
Grantor's total cost of water main extension C '2-O
and dollar amount dedicated to the District S n /1 Z '
Signed and dated this I (, day of IVCUF/vie/f/L , -I-a- ZCc-C
Owner/Grantor
5 c NO6.4 6), 76856T
SDvcHI,z / G, 766,5G
,.'},tiY P/fAri )VIA-y Cc,v,vcT rc 1-w; i z/vr rF/t O/v wyrr) T1y/zr o-/A'/4.
1/t P 5 O/Q CrArb/v5IO/b ke,./TT ivo E-0/51-7./.3 s Co--14,6c 1`F/)
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y L. 5i 7e ca Z
keg e: Pen-fig C CCM/2/Ny r Do/& 5GHKH4't
5-01 w CA tru9 g cc /5. '3Tinf NlvY 60
5 #rftcoD C O ge57 J
Levbc, tvDD . GO US-:5 -7
LITTLE i HOMPSON WATER DISTRICT
DIRECTORS: Telephone(970)532-2098
Preakam 35E.
Tom aideli 8 Highway 58
Drawer G
Ka Cro April 21, 2000 %tu
Kam Croonquiet p BenhouE,Colorado 80513
Gbrn W.GGDnon
Dean Anderson
Cerny J.Sdamaruan
James W.Strch
MANAGER:
Richard H.H.MIMS
Ted Schrage
866 E. Hwy 60
Loveland, CO 80537
Dear Mr. Schrage :
This letter is in response to your request for a water service
commitment for up to 2 residential lots, in the location described
as follows :
PORTIONS OF NE 1/4, SEC. 6, T4N, R68W -- WELD COUNTY, CO
The District provides water service within its service area as
defined by the District . The provision of water service by
extension of existing water lines of the District to the above
property and the installation of taps for lots is done under the
terms of the Rules and Regulations of the District established by
the Board of the District from time to time . You may obtain a copy
of the Rules and Regulations from the District . This letter
outlines the provisions of the Rules and Regulations, however this
letter does not change any provisions of the Rules and Regulations .
The Board of the District may alter and amend the Rules and
Regulations at any time, and the provisions of this letter are
subject to alteration and amendment based on changes in the Rules
and Regulations of the District .
We currently have a 10" Dia . water line located along Hwy 60
with additional capacity available Therefore, we can commit to
provide service to the above property, subject to the limitations
in this letter, for one standard residential 5/8" X 3/4 " water tap
per lot; and the following additional limitations on the provision
of water service are :
LITTLE THOMPSON WATER DI.. [RICT
DIRECTORS: Telephone(970)532-2096
i^ Tom pey^oI+�President
� 635 E.Highway 56
,'{}".�'$ Drawer G
Leo Bake 'ID l 21, 2000
Berthoud,Colorado 80513
Kenn Croanguut •
Glom W.Gibson
Dean Anderson
Carey J.Seomoneon
James W.Senn
MANAGER:
Richard H.H.Mittel
Anthony L. Sanchez
501 WCR 48
Berthoud, CO 80513
Dear Mr. Sanchez :
This letter is in response to your request for a water service
commitment for up to 2 residential lots, in the location described
as follows :
PORTIONS OF SE 1/4, SEC. 6, T4N, R68W -- WELD COUNTY, CO
The District provides water service within its service area as
defined by the District . The provision of water service by
extension of existing water lines of the District to the above
property and the installation of taps for lots is done under the
terms of the Rules and Regulations of the District established by
the Board of the District from time to time . You may obtain a copy
of the Rules and Regulations from the District . This letter
outlines the provisions of the Rules and Regulations, however this
letter does not change any provisions of the Rules and Regulations .
The Board of the District may alter and amend the Rules and
Regulations at any time, and the provisions of this letter are
subject to alteration and amendment based on changes in the Rules
and Regulations of the District .
We currently have a 10" Dia. water line located along Hwy 60
with additional capacity available Therefore, we can commit to
provide service to the above property, subject to the limitations
in this letter, for one standard residential 5/8" X 3/4" water tap
,per lot; and the following additional limitations on the provision
of water service are :
r^�
March 13, 2000
Little Thompson Water .4.--EiT.
Board of Directors ? r. Cook
835 E. Highway 56 , '
Drawer G lj
GBerthoud, Colorado 80513 f
r/
Re: Water Main Extension on Co. Rd. 3 for T. Schrage ,C
f/
and A. Sanchez : (fr 9 ���
Dear Mr. Cook and Board of Directors : W
On March 9, 2000 Mr. Schrage c.nd Mr. Sanchez met with Mr. Cook
to discuss the possible extension of the water main from
highway 60 south on County Road 3 to the property line of Ted
Schrage and Anthony Sanchez then west along the property line
about 800 feet for a total extimated length of 3650 feet.
Mr. Schrage and Mr . Sanchez both have the opportunity to connect
to existing water mains at their property lines then extend on
with a prjsfate 2 inch water line across their properties to the
planned building sites.
However, Mr. Schrage and Mr. Sanchez would perfer to have the
main water line extended which would aid in supplying future
water taps to planned building sites .
At this time we are requesting that the Little Thompson Water
District take an active part in a water main extension to supply
our water needs . We are asking for both your support in the
design and to share in the cost of this water main extension.!==--;--
Mr. Sanchez is presently in the ,proocess of securing a building
permit with plans to build early this spring/ Mr . Sanchez wilt
also need a letter of a tap agreement to secure his building
permit.
C -11,-0,1/410__
Please let us know if you will�ccw to helping us wit this NI/h.-4:04_5
water main extension. G O1�
b V,.- ,
Sincerely,
Ted Schrage Anthony L. Sanchez
866 E. Hwy 60 501 Weld County Rd. 48
Loveland, Colorado 80537 Berthoud, Colorai, 80513
970-669-6556 970-532- 42 '
Lk 'ice &,ti
PLATTE RIVER
POWER AUTHORITY
Estes Park • Fort Collins• Longmont• Loveland
April 5,2000
Mr.Ted Schrage
866 East State Highway 60
Loveland,CO 80537
Re: Platte River Easement on Property
Dear Mr.Schrage:
Platte River has no objections to you installing a water line on the Platte River easement,which is
located on your property. You have indicated the water line will be 10 to 15 feet from the
transmission poles and approximately 5 feet deep. These dimensions are acceptable clearances
from the poles. Please be advised that the transmission line overhead is 230,000 volts and safety
considerations must be given when working around this line.
Approval for the water line shall not be construed as giving up any of the rights granted Platte
River by the easement. You may contact at me (970) 229-5311 if you have any questions.
Sincerely,
PLA 11 h RIVER POWER AUTHORITY
7-2
! (,U,
J vti-i•-. �-G•-5
Thomas W. McCormick,P.E.
System Design Supervisor
2000 East Horsetooth Road • Fort Collins,Colorado 80525-5721
970/7164000•www.prpa.org
Little Thomp''Water District Water Servlce/Llne Extension C"1k List
r,
Project Name SG �/��}�� G Location W GK- 3
Pre-Construction Phase L /ontact Name: no cc N%it6F Phone: G6a- rp 53
Address: $66 Ggiw 6O
// f-aVbllLA-ND. GO fi0$'3 7 Fax:
1 Commitment Request Date
t- Service Area Evaluation In-House: Yes /No Consultant:
Fire Flows Reqd: Yes/No Fee:
Site Evaluation:
NSA- Commitment Letter Date: Conditions: Yes/ No
Water Transfer: Yes/No #of Shares:
Impact Fee:
Elevation/Pumps:
Line Rebate(Tie-In):
W44, County Review Letter Weld / Larimer / Boulder Date:
County Contact: County ID#:
Plan Review Engineering Firm: Contact:
Review Date: Phone:
Permits Reqd: Yes/No
L Copy of MLX Manual Date: 1?— ZOrr Given To:
Private Easements (3/No
vMafn Line Extension Agreement Dale: g• -Am-v.-ZOO O /fig
-^ participation by the District O/No District's Amount: 4z,00/-J-I 17-0,74))
Pre-Construction Meeting Date: Contact:
Contractor Name: J ,tA�/k 5' Phone: rj 7j Z— Z& Zd
Proof of Insurance: s"/No Date:
Post-Construction Phase
As-Built Plans Date: Checked By:
Field Inspection Date: Checked By:
Hydrant Fees Date: # of Hydrants:
Impact Fees Date: #of Lots:
Water Transfer NCWCD Mtg Date: CosUShare: # of Shares:
Fire Flow Test to County and Fire Department Date:
Petition for Inclusion Date: Board Approval Date:
Sill of Sale $ Date: Acceptance Letter Date:
Map In Map Book Streets and Subdivision In Index
- Waterline Project Refund $ Refund Water Costs
Record Inclusions Record Easements
Okay to Sell Taps
# of Taps
WELD COUNTY DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT
1555 NORTH 17Th AVENUE
GREELEY,COLORADO 80631
PHONE (970) 304-6415 FAX(970) 304-6411
Permit#: SP-0100363 Sec/Twn/Rng:06 04 68 PERMIT
Owner: SCHRAGE THEODORE Applied: 07/17/2001
Applicant: SCHRAGE THEODORE H Expires: 07/12/2002
Permit Type: RNEW C--Commercial,R=Residential + NEW,REPair,VauLT
Parcel #: 1061-06- - -
Location: TBD 1/2 MILE S OF STATE HWY 60 06 04 68
Legal Desc:
Description: HOUSE
Commercial: N Residential:Y Acres: 14
#of Persons: 1 Basement Plumbing: N
#of Bedrooms: 3 Bathrooms -Full: 2 3/4: 0 1/2: 0
Water Public: Y Water Source: LITTLE THOMPSON
Water Private: N Cistern: N Well: N Well Permit Number:
Percolation Rate 15,3 Limiting Zone P) ft= in Description c-2.e-lea--a4
% Ground Slope — Direction Soil Suitable (Y/N) y
—Engineer Design Required (Y/N) tit In 100 Year Flood Plain (Y/N) IJ
From the application information supplied and the on-site soil percolation data the following minimum installation specifications are
required:
Chambers
Septic Tank /h'C) gallons, Absorption Trench CcCX0 square feet a 4-
or
Absorption Bed SIS square feet
In
addition,this permit is subject to the following additional terms and conditions:
S Y�'�ca 11F tnnn=.=7L-C t4. � TTc w�M.« Li i vAC'�r e-\-rua /12-30- c-F
/ NOTICE
This permit is granted temporarily to allow construction to commence. This permit may be revoked or suspended by the Weld County
Department of Public Health and Environment for reasons set forth in the Weld County Individual Sewage Disposal System
Regulations including failure to meet any term or condition imposed thereon during temporary or final approval. The issuance of this
- permit does not constitute assumption by the department or its employees of liability for the failure or inadequacy of the sewage
disposal system.
This Permit is not transferable. Before issuing final approval of this permit the Weld County Department of Public Health and
Environment reserves the right to impose additional terms and conditions required to meet our regulations on a continuing basis. Final
permit approval is contingent upon the final inspection of the completed system by the Weld County Department of Public Health and
Environment. This Permit expires one year from the application dates
G
Form:S_PERMT x En irothrfental Health Specialist Date
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
APPLICATION/RECEIPT
Initials: SC
Permit Number. SP-0100363 Receipt Number. HAP-01361
07-17-2001 Amount: $315.00 Payment Method: Check Notation: 105
Owner Name: SCHRAGE THEODORE
Applicant Name: SCHRAGE THEODORE H
Parcel Number: 1061-06-- -
Site Address:
Location: TBD 1/2 MILE S OF STATE HWY 60 06 04 68
Total Fees: $315.00 Total All Payments: 315.00
This Payment: $315.00 Balance: $0.00
Account Code Description Amount
256041400-4221.400 New Septic Permit $315.00
256041400-4221.400 Repair Septic Permit $0.00
256041400-4221-400 Vault Permit $0.00
256041400-4730-400 Potable Water $0.00
Description: HOUSE
Commercial: (Y/N) N Residential: (Y/N) Y Acres: 14
Number of Persons: 1 Basement Plumbing: (Y/N) N
Number of Bedrooms: 3 Bathrooms: Full - 2 3/4: 0 1/2: 0
Water Public: (Y/N) Y Water Source: LITTLE THOMPSON
Water Private: (Y/N) N Cistern: (Y/N)N Well: (Y/N) N Well Permit Number.
NOTICE
Applicant acknowledges receipt of the individual sewage disposal system guide and that the completeness of this application is
conditional upon further mandatory and additional tests and reports as may be required by the Weld County Department of Public
Health and Environment to be made and furnished by the applicant or by the Weld County Department of Public Health and
Environment for purposes of the evaluation of the application;and the issuance of the permit is subject to such terms and conditions as
deemed necessary to insure compliance with rules and regulations adopted under article 10,title 25,CRS as amended. The applicant
certifies theat the proposed system will not be located within 400 feet of a community sewage system. 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 Weld County
Department of Public Health and Environment in evaluating the same for purposes of issuing the permit applied for herein. I further
understand that any falsification or misrepresentation may result in the denial of the application or revocation of any permit granted
based upon said applicaion and in legal action of perjury as provided by law. This application expires one year from the signature
emir-
CJ.I!i-.u.cx'
17 � 0O/
wt r/Applicant to
F RTJIAPP
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