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DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT
1555 N 17TH 631
44.011: 14
GREELEY, CO 80631WEBSITE: www.co.weld.co.us
'DADMINISTRATION (970) 304-6410
FAX(970) 304-6412
O PUBLIC HEALTH EDUCATION AND NURSING (970) 304-6420
WI FAX (970) 304-6416
ENVIRONMENTAL HEALTH SERVICES (970)304-6415
COLORADO FAX (970) 304-6411
November 3,2004
Donald and Cheryl Hackett
15267 WCR 18
Fort Lupton,Colorado 80621
RE:ISDS-No.: 04105
Permit No.: SE-0400122
Dear Mr. and Mrs.Hackett:
On October 19, 2004,an evaluation of the existing individual septic disposal system at 15267 WCR 18,
Fort Lupton,Colorado; Section 22, Township 02 North,Range 66 West,was conducted by Pam Smith,
an Environmental Specialist of this department.
There is not enough information available to determine if 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 3 bedroom residence. There were no visible signs of failure at the time of
inspection.
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.
cerely, jj l
()}Y ( L
Pam Smith
Environmental Health Specialist
PS/cs
Enclosure
2006-0298
L'^'_D COUNTY DEPARTMENT OF PUBLIC " SOE# G t/UO/e2 2
All I•- LLTH AND ENVIRONMENT ORG PERMIT#
1555 N.17°1 AVENUE REPAIR#
irrAV 1.1 GREELEY,COLORADO 80631 LOAN# `
".--. wiik PHONE: (970) 304.6415 ISDS# O W -/l7 C
FAX: (970)304-6411
COLORADO STATEMENT OF EXISTING FOR SEPTIC SYSTEM
(PLEASE FILL OUT IN BLACK INK ONLY)
PARCEL NO. / 3 O 9o22noo ft) cf3 /
PROPERTY OWNER../2O4/4 4-1 / d el aly/hi /y.9-GKZ40NE NO. (3a g) gs7-7_ei ?
MAILING ADDRESS i S A 7 en! /q Fr, O7 a.- I"1� go 6 2/
City State Zip
DESCRIPTION OF BUILDING (ex. house,mobile/modugl ar
7 home,shop,office) 44 n 4,/moo r -
STTE/LOCATION ADDRESS /5€ Aid 6 7 IF A c 7Z'w a gozz_/
W , City State , Zip
LEGAL DESCRIPTION PT PTS0� SECTION -Z-Z-- TOWNSHIP''?/k/ RANGE 66 cei
SUBDIVISION .. LOT BLOCK FILING
CENCUS TRACT LOT SIZE/ACRES___SQ c,r S
COMMERCIAL �YES RESIDENTIAL S NO
NUMBER OF PERSON 1. BASEMENT PL %ING YES O
BEDROOMS 4' BATHROOMS-FULL_ 3/4 1/2
WATER SUPPI pPUUgBLIC NAME
PRIVATE Y O WELI(/NO CISTERN YES/NO 'WELL/CISTERN02p20I7/
SYSTEM SIZE: Septic tank material is constructed of Co.ucrr Ireand has✓NK/N 'ed gallons capacity.
FIELD: Trench )C square feet or Bed square feet YEAR INSTALLED ` 9 7n S
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 panel of ground identified by the above legal � ,-:��ription andiurther states
that the systern$35 not in good working order and to the best of his/her knowledge i ,rii►' failing to function properly.
I furtaer 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.
/61/ 9/0V Ue
l(Lde,V
DATE O7ER SIGNATURE 77�� ������ /
Subscribed and sworn to before me di' day of a(��L�/`f/'t. , 20 0 E ,
By 0 l0^--Vz 44 l
Witness my hang and official seat My commission expiry P-00.V
DATE NOTARY PUBLIC
STATEMENT OF EXISTING INSPECTED &REVIEWED BY
nal/TDCITITATIVT A 7 UT A T ru cure,A T TCT TA A Tr
Form No. OFFICE OF TEL STATE ENGINEER
GWS-25 COLORADO DIVISION OF WATER RESOURCES
818 Centennial Bldg.,1313 Sherman St,Denver,Colorado 80203
(303)866-3581 EXST
WELL PERMIT NUMBER 63373 -F _
APPLICANT DIV. 1 WD2 DES. BASIN MD
APPROVED WELL LOCATION
WELD COUNTY
SW 1/4 SW 1/4 Section 22
DONALD&CHERYL HACKETT Township 2 N Range 66 W Sbdh P.M.
15267 ROAD 18 DISTANCES FROM SECTION LINES
FORT LUPTON,CO 80621- 200 Ft.from South Section Line
1200 Ft.from West Section Line
(303)857-2813 UTM COORDINATES(Meters,Zone:13,NAD83Z
CHANGEIEXPANSION OF USE OF AN EXISTING WELL Easting: Northing:
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 horn seeking relief in a civil court action.
2) The construction of this well shah 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 for the change/expansion of use of an existing well constructed under permit no.82978 and repemhitted for expanded uses under
permit no.227271.
4) Approved pursuant to CRS 37-90.137(4)and the findings of the State Engineer dated September 29,2005.
5) The use of ground water from this well is limited to ordinary household purposes inside one(1)single family dwellings,lawn and garden
Irigation,MSS
6) The pumping rate of this well shall not exceed 15 GPM.
7) The average annual amount of ground water to be appropriated than not exceed 1.16 acre-feet
8) Production is limited to the Laramie Fox Hills aquifer.
9) The entire length of the hole shah be geaphysicafy logged as required by Rule 9 of the Statewide Nontributary Ground Water Rules.
10) The owner shah mark the well in a conspicuous place with well permit number(s),name of the aquifer,and coot case number(s)as
appropriate. The owner shat take ne!vwsary means and precautions to preserve these markings.
11) A totalizing flow meter must be installed on this well and maintained in good worldrg 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 at least 600 feet from any existing well,completed in the same aquifer,that is not owned by the applicant.
13) This well shat be constructed not more than 200 feet from the location specified on this permit
14) Pursuant to CRS 37-90-137(9)(b)and the Denver Basin Rules,no more than 96%of the nantributary ground water withdrawn annually shall
be consumed and the welt owner shall demonstrate to the reasonable satisfaction of the State Engineer that no more than 98%of the water
withdrawn will be consumed.
15) This well is subject to administration by the Division Engineer in accordance with applicable decrees,statutes,rules,and regulations.
16) The issuance of this permit hereby cancels permit no.LLr2/1.
NOTE:The ability of this well to withdraw its authorized amount of water from this non-renewable aquifer may be less than the 100 years
upon which the amount of water in the aquifer is allocated,due to anticipated water level declines. OC 9.e494JLV APPROVED as
. / •_ �� CTL��tT�A Sea
State Engineer By
,Receipt No.0541843 DATE ISSUED 09-29-2005 EXPIRATION DATE 09-29-2006
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