HomeMy WebLinkAbout20010571.tiff WELD COUNTY DEPARTMENT C 'UBLIC HEALTH & ENVIRONMEt
1555 NORTH 17TH AVENUE, GREE-EY, CO 80631 PHONE: (970) 304 +15 FAX: (970) 304-6411
APPLICATION / RECEIPT
__ Initials: SKE
1-.,.mit Number: SP-0000537 Receipt Number: HAP000573
09-05-2000 Amount: $315.00 Payment Method: Check Notation: 1037
Owner Name: SAMBER JERRY & MARGARET
Applicant Name: SAMBER JERRY & MARGARET
Parcel Number: 0727-05-0-15-004
Site Address:
Location: 41611 MARBLE AVE
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: BAR &GRILL
t. nmercial: (YIN) Y Residential: ,(Y/N) N Acres: 1
Number of Persons: 25 Basement Plumbing: (Y/N) N
Number of Bedrooms: 0 Bathrooms: Full - 0 3/4: 0 1/2: 2
Water Public: (YIN) N Water Source:
Water Private: (Y/N) Y Cistern: (Y/N) N Well: (Y/N) Y 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 •perjury as proid by law. This application expires one year from the signature date,.
X( �� - �L. ._ :5---__ 262
ner/ pp icant Date 2001-0571
is RT_HAP •
EXHIBIT
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