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Left Hand Water District
July 5, 2006
Theo Nguyen
3161 Johnson Lane
Erie, CO 80518-7833
Re: 50 NH B1 L8
Acct#4411.01
TO WHOM R MAY CONCERN:
The property located at the above address or legal description is within the
"SERVICE AREA" of Left Hand Water District. The tap fee for the above
named property has been paid. This entities one living unit to receive
water service at this location.
If you have further questions regarding this matter, you may contact me at
the District office.
Sincerely,
Kern. L.. ne /tW
Kim Lane
Administrative Assistant
Left Hand Water District
P.O. Box 210 ry Niwot, CO 90544.0210- Phone 303-530-4200 Fax.303-530-5152 www 1e:thandwater.datco us
2007-1212
,.. Cam-949137
Loan
* 168-40
�. • STATEMENT OF .EXISTING SEPTIC SYSTEM j
(PLEASE FILL OUT IN INK)
OWNER OF RECORD: ialI•A/f l6. 7::4 4/LLrk Phone:
l (; 6s'— /1z 7e
MAILING ADDRESS: S/6 / fltyy 'yy, L.Srivi 5R/ Coll-a. cflva /b
City State Zip
SITE ADDRESS: 3'41-/y 1
City State Zip
LEGAL DESCRIPTION:: PT PT Section
_ Zit ... township Q). Range p4
SUBDIVISION A.4.,1.104.4 Fsre-S' LOT /o BLOCK / FILING
NUMBEB. OF PEOPLE: Z Bedrooms: 3 Bathrooms: 4 Mater Supply #CR7y44 /71~.044/..s
RESIDENTIAL OR COMMERCIAL: AS/O.e.vl7,4 i, Lot Size: cs^ Acres
SYSTEH•SIZE: Tank is Constructed of C -/Y..c=i4/2— and has /0 d 0 gals capacity
(material)
AFIELD: Bed or Trench /f 6 7
/0,5'49 sq. ft. Date System Installed:
You are required to draw a diagram of the system on the reverse side of this
form and indicate position, length, width, and distance from the dwelling.
The undersigned property owner hereby certifies that the above described septic
system Ys 'in fact installed,- as described, and existS at this time on the
parcel of ground identified by the above legal description and further states.
that the system is in good working order and co the best. of his/her knowledge is _not
failing'to function properly.
• I further understand chat any falsification or. misrepresentation bay result in
revocation of any permit granted based upon this information hereby submitted
_ and in legal action fdr perjury as provided by law. -
Date
•
Subscribed and sworn to before me this Day of ��` l /4 L9 q )
by
it X �J s
LA.J
Witness my hand and.official seal. Hy commission expires 3 —oV 1 /4
Date . otary Public
STATEMENT OF EXISTING REVIEWED BY .,
Environmental Protection Specialist Date,
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