HomeMy WebLinkAbout20042337 WELD COUNTY DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT
• 1555 NORTH 17TH AVENUE
,... GREELEY, COLORADO 80631
PHONE (970) 304-6415 FAX (970) 304-6411
STATEMENT OF EXISTING SEPTIC PERMIT
Permit#: SE-0300124 Sec/Twn/Rng: 35 03 67 PERMIT
Owner: MILDRED MAE SARCHET LLC Applied: 12/01/2003
Applicant: SARCHET ROBERT A.
Parcel#: 1209-35-0-00-002
Location: 10084 WCR 28
Legal Desc: 21337 N2NW4 35 3 67 EXC R/W ACROSS NW4 B
EG AT NW COR NW4 S95
Description: RENTAL HOUSE
Commercial: N Residential: Y Acres: 80
#of Persons: 1 Basement Plumbing: N
#of Bedrooms: 2 Bathrooms - (Full): 1 (3/4): 0 (1/2): 0
mater Public: N Water Source:
Water Private: Y Cistern: N Well: Y Well Permit Number: 227381-A
Septic Tank: 1000 Tank Material: CONCRETE
Absorption Trench: 400 sq. ft.
Absorption Bed: 0 sq. ft. Year Installed: 1957
NOTICE
The property owner/agent has certified by Notary Seal that the above described septic system is in fact installed as described,and
exists at this time on the parcel identified above by the parcel number and/or legal description,and further states that the system
IS/IS NOT in good working order and to the best of his/her knowledge IS/IS NOT failing to function properly.
The property owner/agent further understands that any falsification or misrepresentation may result in the revocation of any permit
granted based upon this information hereby submitted and in legal action for perjury as provided by law.
The Statement of Existing Record relies on information the property owner or his/her representative provides,under oath,indicating
current status of the system and representing to the best of his/her knowledge that the system IS/IS NOT failing to function properly.
Issuance of the Statement of Existing Permit for any system does not constitute assumption that the site was evaluated or inspected
during any phase of construction by this Department to meet regulations.
x� ( RC / Io2,c{,o3
En iro ntal Health Specialist
s Date
Form:S_EXIST 2004-2337
Form No. OFFICE OF THE STATE ENGINEER We County Planning Department
GREELEY OFFICE
GWS-25 COLORADO DIVISION OF WATER RESOURCES
818 Centennial Bldg.,1313 Sherman St.,Denver,Colorado 80203 MAY 1 2 2004
(303)866-3581 EXST
WELL PERMIT NUMBER 256784 RECEIVED
APPLICANT DIV. 1 WD2 DES. BASIN MD
APPROVED WELL LOCATION
WELD COUNTY
NW 1/4 NW 1/4 Section 35
MILDRED MAE SARCHET LLC Township 3 N Range 67 W Sixth P.M.
325 CRESTRIDGE LANE DISTANCES FROM SECTION LINES
LONGMONT, CO 80501- 160 Ft.from North Section Line
450 Ft.from West Section Line
(303)772-1230 UTM COORDINATES
CHANGEIEXPANSION OF USE OF AN EXISTING WELL Northing: -- Easting: ---
ISSUANCE OF THIS PERMIT DOES NOT CONFER A WATER RIGHT
CONDITIONS OF APPROVAL
1) This well shall be used in such a way as to cause no material injury to existing water rights. The issuance of this permit
does not ensure that no injury will occur to another vested water right or preclude another owner of a vested water right from
seeking relief in a civil court action.
2) The construction of this well shall be in compliance with the Water WSell Construction Rules 2 CCR 402-2, unless
approval of a variance has been granted by the State Board of Examiners of Water Well Construction and Pump Installation
Contractors in accordance with Rule 18.
r.. 3) Approved pursuant to CRS 37-92-602(3)(b)(I)and the policy of the State Engineer for appropriation of ground water
tributary to South Platte River system.
4) Approved for the change of use of an existing well constructed under permit no.227381-A
5) The use of ground water from this well is limited to drinking and sanitary facilities as described in CRS 37-92-602(1)(c),
for a commercial business. Water from this well shall not be used for lawn or landscape irrigation or for any other purpose
outside the business building structure.
6) Production from this well is restricted to the Alluvial aquifer.
7) The pumping rate of this well shall not exceed 15 GPM.
8) The annual amount of ground water to be diverted by this well shall not exceed 1/3 acre-foot(108,600 gallons).
9) Approved as the only well on a tract of land of 74.75 acre(s)described as part of the NW 1/4,Sec. 35,Twp. 3 North, Rng.
67 West,6th P.M.,Weld County,reference attachea exhibit"A".
10) The return flow from the use of this well must be through an individual waste water disposal system of the _.
non-evaporative type where the water is returned to the same stream system in which the well is located.
11) A totalizing flow meter must be installed on this well and maintained in good working order. Permanent records of all
diversions must be maintained by the well owner(recorded at least annually)and submitted to the Division Engineer upon
request. -
12) This well shall be constructed not more than 200 feet from the location specified on this permit 2
13) The issuance of this permit hereby cancels permit no.227381-A. 5.6
/ �
[tLPPROVED /J Z •
V .7��/
State Engineer By ' f
Receipt No.0522961 DATE ISSUED 05-03-2004 EXPIRATIO DATE `y /i
••
Form No. OFFICE OF THE SATE ENGINEER
�"WS-25 COLORADO DIVISION OF WATER RESOURCES
818 Centennial Bldg., 1313 Sherman St.,Denver, Colorado 80203
(303)866-3581
WELL PERMIT NUMBER 0204 ;'3�' / - -
APPLICANT DIV. 1 WD 2 DES. BASIN MD
APPROVED WELL LOCATION
WELD COUNTY
MILDRED SARCHET NW 1/4 NW 1/4 Section 35
300 CRESTRIDGE LANE Township 3 N Range 67 W Sixth P.M.
LONGMONT, CO 80501-
DISTANCES FROM SECTION LINES
(303) 772-7644 160 Ft. from North Section Line
PERMIT TO CONSTRUCT A WELL 450 Ft. from West Section Line
ISSUANCE OF THIS PERMIT DOES NOT CONFER A WATER RIGHT
CONDITIONS OF APPROVAL
1) This well shall be used in such a way as to cause no material injury to existing water rights. The issuance of this permit
does not assure the applicant that no injury will occur to another vested water right or preclude another owner of a vested
water right from seeking relief in a civil court action.
2) The construction of this well shall be in compliance with the Water Well Construction Rules 2 CCR 402-2, unless approval
of a variance has been granted by the State Board of Examiners of Water Well Construction and Pump Installation
Contractors in accordance with Rule 18.3) Approved pursuant to CRS 37-92-602(3)(c) for the relocation of an existing well, permit no. ,2c.2 7 3/
The old well must be plugged in accordance with Rule 16 of the Water Well Construction Rules within ninety (90)days of
completion of the new well. The enclosed Well Abandonment Report form must be completed and submitted to affirm that
the old well was plugged.
4) The use of ground water from this well is limited to fire protection, ordinary household purposes inside not more than 1
single family dwelling, the irrigation of not more than 0.25 acres of home gardens and lawns, and the watering of domestic
animals. This well is to be located on 10084 Weld County Rd. 28, Platteville, CO, , Weld County.
5) The total depth of the well shall not exceed 60 feet, which corresponds to the base of the alluvium. At a minimum, plain
casing shall be installed and grouted through all unconsolidated materials and shall extend a minimum of ten feet into the
bedrock formation to prevent production from other zones.
6) The maximum pumping rate of this well shall not exceed 15 GPM.
7) This well shall be constructed not more than 200 feet from the location specified on this permit.
NOTE: To insure a maximum productive life of this well, perforated casing should be set through the entire producing
interval of the approved zone or aquifer indicated above.
0000
.PROVED //� .4d T
7• ,nvvtc, /f(/.(XAll�llM2
State Engineer By /
,Receipt No.04637098 DATE ISSUED JUL 2 0 2000 E PI'ATION DATE JUL 2 0 2002 ,
Fes°; t r 'PUMP INSTALLATION AND TEST.REPORT
� ,4';-
10194'1,'`.3 For Office Use only
f.,:x :STATE OF COLORADO, OFFICE OF THE STATE ENGINEER
IwELI #P,ERIMIT+NUMBER •12.__;___531 --1___A________
Z OWNERNAME(S) _KtILDREII 2Q �T
Mailing Address apn c Q sTR I Dr I_ i
Cit}F`Sttizo014ac,(_pnKOr.IT cc
Phone`(308,1)o `7-G
3. WELL-.LOCATION AS DRILLED: K1\n/ 1/4
DISTANCES FROM SEC. UNES: X1/4, Sec.35____T p _�_ Range (7_
16c1 ft. from t ia/ttf or EoiR� Sec. line. and k-g ft. from �-
SUBDMSION: If dt€ rt i Win/CSec. line.
ea a
STREET ADDRESS AT WELL LOCATION: LOT BLOCK FIUNG(UNIT)
4. PUMP`D_ATA:Type g_ �?t>3t-1ERSInF,L Installation Completed A—II-OO
pump`:,Manufacturer s
Design GPM 10 at RPM 8(_�Op _ Pump Model No. InCrsp i
Pump Intake Depth HP �_, Full Load Amps q
P �_ Feet, Drop/Column Pipe Size
Inches, Kind PVG
ADDITIONAL INFORMATION FOR PUMPS GREATER THAT 50 GPM:
T1413¢INMP..RIVER,TYPE:.:E Electric ❑ Engine ❑Other
Design Head _feet, Number of Stages
Shaft size inches.
5. OhHERr EQUIP,MENT:
Airline Installed❑Yes®No, qnflce Depth ft, . Monitor Tube Install d ❑Yes-X. No, Depth ft.
low Meter Mfg._ N/A g
Meter Readout El Gallons, l—� Meter Serial No._� p
1 Thousand Gallons,El Acre feet,Q Beginning Reading
-1,q.tr,n chhitin 'r:
6. TEST.DATA:., C Check box if Test data is submitted on Supplemental Form.
ToiallV��ll`b ptth' r Date Time
—I I -
Static Level �i �' Rate (GPM)
Date Measured �j_ 1 Fpcj I
Da•CtIlte
n, • Pumping Lvl. _•I
DISINFECTION: Type N T N
Amt. Used 1 CUP
a Water Quality analysis available. ❑Yes ❑ No
1916W t)pl.S.. ii,t.'(sr ,. .
9. Remarks
•
0. I have read the statements made herein and know the contents thereof, and that they are true to my knowledge.
(Pursuant to Section 244-104 •(13)(a) C.R.S., the making of false statements herein constitutes perjury in the secon.
degree and is punishable as a class 1 misdemeanor.]
Cr\RACTOR��Q 1 , 1Et t P!t-r(�
Math,ig'Address PO n 5�� c_',R Ina
Phone (9Q)�53 3 I t Lic. No.¢}52
Name/Title (Please type or print) fc(1/
p ) Signature
e /� Date
4 2/i 6 viti ✓ ' - / - -r.6---z.--- e==7
J/Pa'
t,
`oit "" � � WELL CONSTRUCTION AND TEST REPORT
ew53] � For Office Use only
101,4 " ° STATE OF COLORADO OFFICE OF THE STATE ENGINEER
el- .WEl1_,PERMIT,NUMBER . , .2 ?. 3R 1 - A
..... OWNER'NAME(S) I"'MILDR2D SA-RCHET
•c-I MaitirigiAddress- ?cc) C R "ST R I Dr;G I_A N E
City, St Zip LeING-HON T, CO , cc-O5O1
Phone (3c 3) 7_72 -.7b l+y.
3. WELL LOCATION AS DRILLED: N W 1/4
NiU 1/4, Sec. 35 Twp. 3 N Range 64- W DISTANCES FROM SEC. UNES:
I (DO ft,from NORTH Sec. line. and I�L50 ft. from W L ST Sec. line. OR
,rr :,e RI t,.aJ,•_•d (norm or sown, . (east or west'
SUBOMSION:
LOT BLOCK FIUNG(UNIT)
STREET ADDRESS AT WELL LOCATION:
4. GROUND SURFACE ELEVATION ft. DRIWNG METHOD RO-T Ally
DATE'COMPL ETED e -'2,-0,-, . TOTAL DEP T FI So ft. DEPTH COMPLETED
74 ft.
S. GEOLOGIC L( G. .., 6. HOLE DIAM.7�, (in.) From (ft) To (ft)
Depth Description of Material (Type, Size, Color,Water Location) a/+'5 0 8 0
•0 a :TCta•PSo1L
-2-7•1780,,,eei,ou)N ,Ct-,4Y
f3-442 14;0 1b;CA-ND -GRAVEL
3R- 4-6 `S3•ROWN CLAY 7. PLAIN CASING
14-1n-50 SAND C-RAVEL 'Ft NL" To ROCK OD (in) Kind
Soy6-5)taRlRnt;Nr"'C1`h'Y ( . Wall Size From(ft) To(ft)
STEC/ • TSB F I aCJ
65=tgO7:$.A:ND c:RA-vet: Pi NtE To Rock
5 PVC P44rN • a7 a 5ti-,JO-Ro YELLOW CLAY WITW Si4ALC MIX
.:N:: actor; u
PERF. CASING: Screen Slot Size:
5" PVC PLZF •�7 51+ 4
8. FILTER PACK: 9. PACKER PLACEMENT:
Material Pl`q C.QA V L Type
Size
;r.,w..• : Interval O- Depth
10. GROUTING RECORD:
REMARKS: Material Amount Density Interval Placement
(EtierJT 3scxS 1. 86 c)-,-20 Poot2 I
•
111.:15i51tn CTi"btP`TyiSle It THi Amt. Used
r e_uP
la.WELLITESL.DATA: Check box if Test Data is submitted on Form No. GWS 39 Supplemental Well Test.
yTESTING?METHOD' 'epA-I I'E tj
Static Level ft. Date/me measured g 00
,PUfftp1ng"feveW=1 tI ft Date/Time measured Production Rate I�
8 3 00 Test length (hrs.) rs 9Pm
1 have read the statements made herein and know the contents thereof, and that they are true to my knowledge. [Pursuant to Section 24-4-104 (13)(a)
CRS,the making of false statements herein constitutes perjury in the second degree and is punishable as a class 1 misdemeanor.)
P9.NT,FRKT(Q„31rn g1442 IA J \f Pu t- 3( P . Phone (q70) 353- I t e Ljc. No: 8 57- .
Mailing Address q Bok 57-74 r E L 11 Co g0 6 a2
Name/Title. (Please type or print) Signature _
COLORADO DIVISION OF WATER RESOURCES Office Use Only
DEPARTMENT OF NATURAL RESOURCES Form GWS-45(1/2004)
1313 SHERMAN ST.,RM 818, DENVER,CO 80203
phone-info:(303)866-3587 main:(303)866-3581
fax:(303)866-3589 http://www.water.state.co.us
GENERAL PURPOSE
Water Well Permit Application
Review Instructions on reverse side prior to completing form.
The form must be completed in black ink.
1. Applicant Information 6. Use Of Well (check applicable boxes)
Name of applicant, ,§�� `
/'/o app I4 J Aft i /j C Attach a detailed description of uses applied for.
Mailing address 5On
+Y�
_ /jjj/ ) ❑ Industrial ❑Other(describe):
.2(5 cp<7t/ 5 e Avs% El Municipal
City I tarn
Ter AJ/,/(11 Zip code ❑Irrigation
aj /”..c741- Cc c-t-)Se / ommercial
( ib ) 77:2-/...z. 34) 7. Well Data (proposed)
2. Type Of Application (check applicable boxes) Maximum pumping rate Annual amount mbe withdrawn
El Constructp Construct new well 0 Use existing well Total depth
e Wm acre-feet
❑Replace existing well lCange or increase use Aquder
❑Change source(aquifer) ❑ rm
Reapplication(expired permit) feet
❑Other: 8. Land On Which Ground Water Will Be Used
A. Legal Description(may be provided as an e actment):
3. Refer To (if applicable)
Well permit# Water Court case Is
�� 7 3�"/� S sc�/ _T
Designated Basin Determination a Well name or N
4. Location Of Proposed Well (If used for crop imgafion.attach a scaled map that shows Irrigated area.)
County ����// j
INC��d /1al B. LAmros C. Owner
/u/ „<of the �✓w „Q TX;
a 75-
n /Section Township N or S Range E or W — "� l/'/i did 4, �..�.</J� ��
35 �❑ Principal Meridian
r"` .5 3 /7 ❑re/ 674
D. List
List/any other wells or waterrights used on Nis lantl /
stance of/well tram section lines(seectt tt lines are typically not properly lines) ,.�,// V e S x,„ A-,74,, Al e. o;.4/ 1.-3A-6. W-
/be Ft from L✓J N❑S 95-0 Ft.hom❑E�1W
For,eplacementwellsonly-distance and direction from old well to new welt 9. Proposed Well Driller License#(optional):
feet direction 10.Signature Of Applicant(s) Or Authorized Agent
well?oration address(a a )--`-------------------___-_____ The making of false statements herein constitutes perjury in the second
!t +� 'f.plpiicable C A ^f degree,which is punishable as a class 1 misdemeanor pursuant to C.R.S.
1 A 24-4-104(13)(a). I have read the statements herein, know the contents
------ thereof and state that they are true to my knowledge
Optional: GPS well location information in UTM format Required settings for GPS units are as follows' Sign(Tore(Must be original signature) Date
Format must be flu ///J +hJ
Zone must beta /� -'� 9„ � ._.. /ll��/<�
unds must be Meters Northing /Pent non/e18 the C/ /✓'✓✓//TTY-/-/�e4/f )�
Datum must be NAD2 CONUS) Basting t I er/ �JN C/ir�/'/!�/Ll�r /�f,#n 1 �,p
Unit must be sot to true nor /'r /<rRC �,'7a�<�/t�•C.
Were points averaged?❑YES ElNO Office Use Only
5. Parcel On Which Well Will Be Located uscs map amp DWR map no. Surface elev.
A.Legal Description(may be provided es artattachmenty Receipt area only
Tile ihrr r &'c a C A ,e' weer F,srA,- + S--
Sec1/in* ” 7•wi.,hy 34:-. r J,,ya <74 wa,7eY
ff,2Chi ,'4. WaagC'wt�Ya/nnol eyevt Ay- f/z".ret-
K ,,¢coral.,/AC er nA '.. 077 oa,4 %C.JYS, 4.
`c3C 36 j/ We4 Covnf /'ectr4 oc-ael
lee_ t( t lec-tt-
B./I of acres in parcel C.Owner (" W E
7€1 7y" .e/ t')G1C/CfiAAG WR
D.Will the be the only well on the parcel? ES UNO(it no—list other wele) CWCB
+r,
TOPO
. State Parcel(De(optional):
MYLAR
805 DIV VVD_ BA MD
srado Division of Water Resources Application Receipt No.
13 Sherman St.Rm.818
venver,CO 80203 - Applicant's Name
(303)866-3581
.— http://water.state.co.us/default.htm
COMMERCIAL SMALL CAPACITY WELL WATER USE BREAKDOWN WORKSHEET
(For Wells Located Within Designated Groundwater Basins)
Name and Type of /
Business___drre; k e /. e/r✓ S-n.•cr L IAA'I/ 04':/j, 1 4 iJ on._�sn 7 CAL,, f
1. Is this application fora new well?
Yes
i!No If no, is this application for a change of use for an existing permitted well?
/Yes Permit Number of well (if applicable) ;J-7
No For wells used prior to May 8, 1972 see form GWS-12 Registration of Existing Well for
further information.
2. Type of disposal system:
l� Septic tank/absorption leach field
Central System (district name:)
Vault(location sewage hauled to:)
Other(attach copy of engineering design)
3. Water Demand Calculations(for average factors for water demand see below)
Employees
Number of Employees X Number of Gallons per X Number of Days Employee = Gallons per Year
Employee per Day Works per Year
X id X LSD = ): Ccye A
Customers
Number of X Number of Gallons per X Number of Days Business = Gallons per Year
Customers per Day Customer is Open per Year
(9 X X = B
Outside
Square Feet of X Number of Gallons per X Number of Days landscape = Gallons per Year
Irrigated Landscape square foot per day is irrigated
C� X X = C
Other Uses-Provide breakdowns for all other substantial water usage(i.e. veterinary clinic,green houses, etc.)
Type of Use X Gallons per Use per X Days per Year = Gallons per Year
Day
ro''e X X
— D
Total amount of water required: /o,, 004 _gallons per year
(A+B+C+D)
,d307 acre-ft per year
(1 acre-ft= 325,851 gallons)
For all small capacity commercial wells:
1. The pumping rate shall not exceed 50 gallons per minute and may be further limited by Water Management District
Rules.
General Guidelines for Water Demand in Gallons per Day
Day Workers at Offices—15 galbns/person/day
Food Service Establishments(with toilet and kitchen wastes)—10 gallons/patron/day
Churches(does not include food service)—5 gallons/seat/day
Overnight Lodging—50 gallons/customer/day
Landscape Irrigation—45 gallons/1,000 square feet/day
On-Site Proprietor of Overnight Lodging(i.e.on-site owner of a Bed 8 Breakfast)—80 gallons/person/day
Additional water demand figures may be obtained from a private water consultant or from a technical reference on this subject. GWS-61
03/03
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