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Mr" iiiiir DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT
GREELEY,1555 N 17TH AVE
GEEL CO 80631631 WEBSITE: www.co.weld.co.us
'lip
ADMINISTRATION (970)304-6410
FAX(970)304-6412
O PUBLIC HEALTH EDUCATION AND NURSING (970)304-6420
FAX(970)304-6416
ENVIRONMENTAL HEALTH SERVICES(970)304-6415
COLORADO
FAX(970)304-6411
June 15,2001
Lawrence Hertzlce'
DBA West Colorado Square
4902 West 12*Street
Greeley,Colorado 80634
Revised Letter. Statement of Existing dated 06-14-2001
RE: Lawrence Hertzke ISDS No.: 01-062
Permit No.: SE-0100066
Dear Mr.Hertzke:
This is an updated evaluation based on the revised Statement of Existing dated June 14,2001.
On May 24,2001,an evaluation of the existing individual septic disposal system at 22670 County Road 54,
Greeley,Colorado,Section 26,Township 05 North,Range 65 West,was conducted by Pam Smith,an
environmental specialist of this department.
0^
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.
This evaluation was conducted as a part of a recorded exemption request through the Department of Planning
Services. It should be noted that the existing septic system should remain on the lot with the house as a result of
the recorded exemption.
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 information the property owner provides,under
oath,indicating current status of the system and representing to the best of his/her knowledge the system is not
failing to function properly.
If we can be of any further assistance,please contact our office at(970)304-6415.
incerely,
amSm
Environmental Health Specialist
PS/ske/hertrYe lawrence revised
Enclosure
cc:Weld County Department of Planning 2004-2075
WAX, TT�Q COUNTY DEPARTMEN PUBLIC ^ SE# C) / Cl O 0 Co
H. _TH AND ENVIRONMENT-El J' ORG PERMIT#
• r Ant,..,„,„ GREELEY,COLORADO 80631J(/N E1555 N. 17Th AVENUEjV-et) OANREPAI# #
PHONE: (970)304-6415 / y 20 ISDS# �'i 1 - C�L,
Alive FAX: (970) 304-6411 41004//40741
JOLORADO STATEMENT OF aitt$EPTIC SYSTEM
(PLEASE FILL OUT IN BLACK INK ONLY)
PARCEL# O9 ( l.2.(o coo o3S
PROPERTY OWNER l-awec.oee /. Weetzke .)Ail iUeSi PHONE NO. (970) 3S3- o0'7S
Colozgdo Syua2z
MAILING ADDRESS y9o2_ a)es+ Iz+&. (,Reele, 0n Ro(azq
City State Zip
DESCRIPTION OF BUILDING (ex. house,mobile/modular home,shop,office) /-(on+s e-
SITE/LOCATION ADDRESS .=.2 67o UYe.. .s`f ( Ree Le/ CO Y,ota/
City i State Zip
LEGAL DESCRIPTION PT PTA_ SECTION -26, TOWNSHIP .6 RANGE 6,S
SUBDIVISION LOT BLOCK FILING
CENCUS TRACT LOT SIZE/ACRES 2O
COMMERCIAL YES O/ RESIDENTIAL YES NO LL�__
NUMBER OF PERSONS `4 BASEME LUMBING YES/&O_
BEDROOMS 3 BATHROOMS FULL 13 3/4 1/2
WATER SUPPLY PUBLIC &NO UTILITY NAME CeeQ I (,()e.i ci
PRIVATE YES/NO 1 CISTERN YES/NO WELL YES/NO WELL PERMIT#
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SYSTEM SIZE: Septic tank material is constructed of Cb,Uo t,44. and has 1.000 gallons capacity.
FIELD: Trench - , - square feet or Bed 6 94o square feet YEAR INSTALLED Os KnowA)
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 de Option and further states
that the systen�is not in good working order and to the best of his/her knowledge i is no 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.
6- /y /- O1 fitW Veil e.e il #Ae.f zK ) 'c� 4
DATE OWNER
Subscribed and sworn to before me this / / day of ae0
by 1A.td real ee 14 AlFittz . _.--,••..
to• ".... n
B I�IwIC.C
Witness my hand and official se: : '4, "....N.%/1 N�/C1,� y commission expires: 9, �0 3
i
,./O_ W loo ! 1. ( EVELYN M. � g:. � , ���u-1C-l-e.�-
A f ,�tot BUS V OTARY PUBLIC
'i f s... Q,
STATEMENT OF EXISTING ' ' ,,t' / >�I� ..
�`‘'....„..-- ENVIRONMENTAL HEALTH SPECIALIST
*Cuiimt 3
r RECD AUG 2 0 2001.1
WATER TAP ASSIGNMENT /5/
FVALUE,R5CEIVED, I/we hereby sell transfer and assign to
t•1
l_
_ b_ /a • ter--1 , „ ti „ , cr '1,Lt;_1t .`MMLC: L/',3,t4At ± / water tap(s) in the
CTRAL WELD COUNTY WATER DISTRICT, on my/our property described as follows
situate in Weld County, Colorado, to wit:
r
am. ,
',2L._C.. al la d t �. � ..
IT IS UNDERSTOOD that these taps were purchased for the above described land and may not
be transferred to other land, without express, written consent, in addition to the below consent,
of the CENTRAL WELD COUNTY WATER DISTRICT. I/we further authorize the Secretary
of said District to do any and all things necessary to effectuate this transfer on the books and
records of said District. I/we hereby state that all water rates and charges and other monies
owed to the District have, been paid and if not, shall be held out at the closing of the sale of
my/our premises.
I1 TESTIMONY WHEREOF, I/we have set my/our signature this '' `
rh-C-9,i - , r /7)(, �. / Y g /w ' day of
f We Colorado Square, LTD
* SELLER: Lawrence H. Heftzke
** SELLER:
I/WE FURTHER AGREE to pay any and all charges hereinafter levied by said District for said
taps and to abide by all regulations adopted by said District.
ACCpT'TED:
** BUY Jose A. Aguirre
,_• *r_YER Josefina Aguirre
CONSENT TO ASSIGNMENT
'� I, John W. Zadel, General Manager of the CENTRAL WELD COUNTY WATER DISTRICT, Hereby consent to the above assignment on behalf of said District.
B;rekr •
DATE: ��/r,
** TO PERSON EXECUTING THIS ASSIGNMENT - NAMES AS THEY APPEAR ON
TITLE MUST BE TYPED AT THE APPROPRIATE SPACES, FAILURE TO DO SO WILL
NEGATE THIS TRANSFER. TWO ORIGINAL TAP ASSIGNMENTS MUST BE
COMPLETED AND SENT TO CENTRAL WELD COUNTY WATER DISTRICT FOR
DISTRICT CONSENT.
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