HomeMy WebLinkAbout20093038.tiff WELD COUNTY HEALTH DEPARTMENT
1555 17th Ave. No. �I l
Greeley, Colorado
yv;
or Permit to Install, Construct, Alter or Repair Individual Sewage Disposal System.
onsor Address Phone
p I-, ri , yFT
Ste , f ress /SF [/ / / 4 4e _ s
General Information ,. ; Septic Tadk s C- . - ,'
1. Liquid Capacity y�
1. Living 'Units _� 4 P y --/J Gallons i- 1 . •.
2. No. of Bedrooms c- 2. Dimensions W L D .../ /- >nc,
3. No. of Baths i — 3. Material 44,,A I i._�-rC'
4. Basement Drain ---ti e 4. Type Inlet
5. Automatic Dishwasher - _'ti. 0 — Type Outlet
6. Garbage Disposal -6
7. Automatic Laundry t---C) Secondary Treatment ! ;,,, ti
8. Size of Lot 2— .t ' -t'--/ — --> •
9. Type of Soil ass....—..a.— Field MCA") cC,'-i Fr Bed -301 �4_Fr-
10. Percolation Test /A/. /4/Nle ru_s_ 1. No. of distribution lines _i'l4 t AI CF I w
11. Water Supply C.-E-- 2. Trench: Width LengthiL2 ' al&X
12. Lot Grade
3. Type Filler Material (.-.f35A c-« ' t=ci, z
13. Water Table Depth 4. Depth of Filler Material V Uncle, 2 'led R Tit,
14. Other 5. Gravel Size -3/-1 - Z "
6. Type Tile `i ILIA PLI4STlCD C* (MOW ti(7 t
• 7. Depth of Cover
8. Other 11 '' TG rA. C-R/a,)=i- D i)T+h
The Permit is to remain in full force and effect for six (6) months from date, until revoked for non-compliance.
This system will be constructed in accordance with the above specifications and regulations governing non-
municipal sewage disposal systems, in accordance with Regulation No. 1 of the Weld County Health De-
partment.
Date: /�� �D / /&/ i Applicant: s'--",- �j/ -r ,�c ^
The plans and specifications as shown are approved, pending paymeniof. ermit fee.
Sanitarian: A « o 4
Date: A' // / % f1_
The above system inspected--9,nd found to comfy-with th/plan and description. ,
� ,. /a . �t /./: %/
Installed by / 7 ) , = 7 i '/ _,Date: /,
9
Sanitarian: -t'-E.7 e l - . ° , .
o4'
PERMIT FEE $ ,%1 - , s ' _
"'Received by =-" ''6-a'� lk Date � �
Please use reverse side for Plot Plan or use separate sheet of paper.
2009-3038
• • .._
"O
1 S
i
1
r
j7 ,
I .,- ' J .7
E d /
i o
toll c_ I Q
L —7.
3.` ! 7
1
I
,AUNTY HEALTH DEPART it„1 • FEE $10.00:
rONMENTAL PROTECTIONS VICES �uLLL.a114t1u/ SOE #: 7Z II3 (o
',./ 16th Avenue Court LOAN #: OK y-c3
ceeley, Colorado 80631 �VeldCotuttyFieahhj�eparai ISDS #:
(303)353 0635 REPAIR #:
•
STATEMENT OF EXISTING FOR SEPTIC SYSTEM
(PLEASE FILL OUT IN BLACK INK ONLY)
OWNER OF RECORD: W at SW COW„ A/C CAS 0-0_4 5-- a PHONE(363) 4(c-(4k2
co, r
MAILING ADDRESS: 15(5 7 0 �pSS S € UV.e&A Yw t^ (el{o ' O02. I
Q City State II Zip
SITE ADDRESS: �q 3 W oU WI l_a g7 Pfrvk LA, eilr— Cal 0
City State Zip
LEGAL DESCRIPTION: PT:1u ,cUf X7`4 PT: IA/≤V4 SECTION: /) TOWNSHIP: / N RANGE: 6 W
SUBDIVISION: LOT: BLOCK:_ FILING:
NUMBER 0 PEOPLE: I BEDROOMS: 3 BATHROOMS: / WATER SUPPLY:c (q/O.U�1
RESIDENT / COMMERCIAL BASEMENT PLUMBING: Y LOT SIZE: ,(, c acres
SYSTEM SIZE: Tank is constructed of C2Nletur and has - /DDO gallons capacity
(material)
IIIIELD: Bed Tjtoo.dL or Trench ,11..E square feet. DATE SYSTEM INSTALLED: 61/4/7d
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 description and further states that the system is in good
working order and to the best of his/her knowledge is not 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.
Aitc 9 S . (2_6(--IA- 12,Pil,k-itv, wetu -t-Q,4 6...,:i
- - / Dfiz.1 rr '(LcQ €AiS co-( tNe
WA
Subscribed and sworn to before or me this /4 // day of- ,�� , 1991,
by 72(7-�( (/.�i(�Ll -7 (4/Oil .CL1 41 ,rrr.-v,) ' eviliSici
/ (c .2-
Witness my han and official sea . Myy ission expires: C
• /iD -3 l (f)/ vfl/ (
Date / Notary Pub
STATEMENT OF EXISTING REVIEWED BY:
Environmental Protection Specialist
w,
MAY-1e-2005 M0N 12:05 PM C•WELL BANKER FAX NO, 3 72 9078 P. 01
•Form STATE OF COLORADO For Office Use Only
No. OFFICE OF THE STATE ENGINEER
0WS-11 818 Centennial Bldg., 1313 Sherman St., Denver, CO 80203
6/2003 (303)866-3581 Fax(303) 866-3589
CHANGE IN OWNERSHIP/ADDRESS Ilectit/E0
CORRECTION OF THE WELL LOCATION 4/411 /6
zoos
Insert the Well Permit Number `o,osr(A
Name,address and phone of the person claiming ownership of the well:
NAME(S) C.CIS\oS.. eir.S'l\earo✓Sj
Mailing Address q 9 `f-3 C-2. 3 ^
city, St.zip_ r---1-• _t-Ur+DA C WOG a.-
Phone ( 4-10 1 T y 2
This form is filed by the named individual/entity claiming that they are the owner of the well permitted as referenced above.
This filing Is made pursuant to C.R.S. 37-90-143.
WELL LOCAION: County k_dipe 1 c Owner's Well Designation
(Address) (City) (State) ll (Zip)
• N 61/4 of the_ .6.1/4, Sec.a.,Twp._,.�,._.��N. or O S., Range /'4 L. ❑E. or W,.J� P.M.
Distance from SeQtiotlLines _ . _ Ft. From 0 N. or 0 S„ _ Ft. From 0 E. or 0 W. Line.
Subdivision Name, b I t __ Lot ,_Block a , Filing/Unit_ _
The above listed owner(s) say(s) thatth�helI she(they)own the well described herein. The existing record is being
amended for the following reasons: 1246 Change In name of owner 0 Change in mailing address
0 Correction of location for exempt wells permitted prior to May 8, 1972 and non-exempt wells permitted before
May 17, 1965, Please see the reverse side for further information regarding correction of the well location. —,
I (we) claim and say that I (we) (are)the owner(s) of the well described above, know the contents of the
statements made herein, and state that they are true to my(our) knowledge.
Please print the Signers Name&Title Signature(s)of new owner. Date
C46,124.06 Pc r Gsr4i R4S _ Sl i3 *'
it is the responsibility of the new owner of this well to complete and sign the form. Signatures of agents are acceptable If an
original letter of agency signed by the owner Is attached to the form upon its receipt.
For Omee the
Only
kCCEIH ED AS A CHANGE 1N OWNERSHIP
• ea AND/OR MAILING ADDRESS.
, A.,e it , 40„462%
State Engineer By Date J
Weld County CO JA Sulu Tsukasnto Clerk I. Recorder II.UU
n'll RECORDED EXEMPTION NO: 1471-12-I-RE 2042 PROPERTY DESCRIPTION
'TIE NORTH I/2 OF THE NORTHEAST 1/4 OF THE NORTEAST I/4 OF THE NORTHEAST 1/4 THE.N(Nlnl UT 1H T11E NORn1EANr G
�„\ 111"1711 NI IRfEA➢T IN 1 W'INF.*WEIR
Crlp' OF SECTION 12,TOWNSHIP I NORTH,RANGE bt WEST OF THE 6th P.M. 111,MI ILION 12.took MHP I NON'n I.
/i" '\� I� fG/ C:()UN IY Ill WELD.STATE C)}'COWRAIKJ. RANI*/*WRT FIILKI Y II1F THY M FFF.
. '1'AND
1 RESERVE!)14*WEED CININIY WWI I
1'1NINIY 1*WELD STATE 1*CI IIAR M
SURVEYOR'S CERTIFICATE
Amstar Ws* *All ix X 1*td II * 'IRO HERESY 1 IA 272•11,A)IjINlil
M _ AW I'IHYNHHUNNTATI YN114 IMPISH WITH NE IP11mIP
WAS HOMMINUNE**MY THE 1,
`-Oro •
rim PIA
IYN MAIKL STATE NI
ANIO PRNIAWNaA11ANH MR\� .
VICINI•IY MAP terry icy -3i'i o
1": 000' M IXNk11A11 lira P. 1.]nw '
_�. Ina,II '.";r.; 4.9 FOUND NIANITHAST GUNNER 1 1lin-an au
.s SlrH'1ON 12.'11N.RenW , '•...,
I
�,j' Al 11 MI WInI OWNER''APPROYAT
F I E2NINII NORTH IN 4. Y µEMSNUM I AP IN NANFE tlO%
Nl:I'17UN 12.'f IN.NMW 11234'1].IMO
e WI..11111111400K AND I IN 1 lad KM,
�e NERAR WITH I M.INIi'I OIL!RATE OWNER IYI U!IIIC.
"^""' ' • 'I IN'ALUMINUM CAP — PMIPF#IY DO HERESY W NMVIIIF THE➢
S 211417.10114 �r I III AI'IAl'l1EPA1AP WI TOM woof
1
N!WI9WW WE:IJI COUNTY R MD 12 no ROW R UNI*SAIANH THIS PROPERTY I➢Hk:ATI
;IN Raw r1. nitwit*
INNTRN"f AND IN MIR>INRNU!]l
NI R'11111NE 111"17H NE 1/A NIA"1ION 11.'f IN.NNW YMWRN.ARMS HAN THE I ONYUC I 11E 1
i, i N NrIV'Io•W '127.32' ql N11PI41e'W 247.32' PBCf— MITI Iq 11Y OSE➢,ANTLNJE➢ Y➢PFCW.
I e 17930 WCR 12 MI �_ /
'S I I� t 7.-3 L
!= WWII) Then 247.7.11>RE OWNER P.�T e
! n "
b IAH'H f IAa'A ^ $I@ •
S811; El Ikh:litl'1A(YON'n:OWNER DO
p? 2.211 Al RFS MINH:11111 E:SS t..in 1.o]µ'2HN MIIW':tilt LI:Sc MI!FG.!'
R e Wg
�033 034 $ gl x
LEGEND: $ 7l yy lay iirxlAe HE#:1'F1}' ) r`tw4
• uM ain MA:NnANP MOMWFII 4943 WCR 37 Z r3�q 17 SCI /
AS Nara)E MMIN Ma y
yp MY CUMMINSION E➢PIEUiAq e y'
▪ I*.M,111 a I MIINnMn"1 al 11Y NISAM NN9'1'A'x1'F N➢V'IW'W'1'. ISIYIlN11aNE I.1 L/ /
4.3O
Wr111 all Ma ar'(AP IS 17211 9
NOTARY It SIN)
.3>I wa.INaMWI+:Im WITNESS MY I lE
A, scommot in iiiirrica it,
119 ION ala is UM wnlun NO'!x:
3.' mn.M Nam lunar all
3 All calmly 1Mwlule MN or du
**Wiwi nmulre IWnM Wr Ua aNW lLLMkl
it" AMINOI IASI IA CORNER ACCEPTANC'F
FOUND CENTER I'IRNER SFr TION 12.TIN.E M Y
*COON 12. FIN.RMW 410 RERAN WIIII. . unity,..•. VI plat M map?*and spr ee*1411*
MI
W RJ-26-72
COLORADO DIVISION OF WATER RESOURCES
THIS FORM MUST BE SUBMITTED 101 Columbine Bldg., 1845 Sherman St. dw'"
WITHIN 60 DAYS OF COMPLETION�p Denver,Colorado 80203
THE WORK DESCRIBED HERE-t.,.- /ipTYPE OR PRINT IN BLACK C/ WELL COMPLETION AND PUMP INSTALLATION REPORT
I K. PERMIT NUMBER 50954 r,,> --'
WELL OWNER Mark Quay NJ. ` %of the N.1$. Y4 of Sec. 12
ADDRESS Rt. 1 Box 36B Commerce City Colo. 800212 1 N. R. 66 v.. ` 6 P.M
DATE COMPLETED - , 19___ HOLE DIAMETER
WELL LOG 6 in.from 0 to 158 ft
Water
in.from to • ft.
From To Type and Color of Material Loc. —
0 14 top soil and clay in. from,, to ft.
14 17 sand
17 27 clay CASING RECORD: Plain Casing
27 32 0
sand
Size 4' & kind Etta from 0 to 110 ft
Plastic*50 100 MEM shale
100 102 rook Size & kind from to ft
102 109 shale
109 114 sand x Size & kind from to ft
114 119 shale
R
119 138 sand Perforated Casing
158 139 rook 4} AMU from 110 to 158 fl
139 148 sand g Size & kind
048 158 shale Size & kind Plastick from to fi
i
Size & kind from to ft
r
GROUTING RECORD
Material Cement
Intervals 0 To fll%ft.100
Placement Method IMA3XISMILVI pird in
GRAVEL PACK: Size Hot Pea 3 3/8
Interval 100 to 158ft.
TEST DATA 7-
Date Tested AMU May 30 , 19 21
Static Water Level Prior to Test 91 - f
May 3072
Type of Test Pump
Length of Test 24hr.
• Sustained Yield (Metered) 15 L.A. C,P.N.
TOTAL DEPTH 158
Use additional pages necessary to complete log. Final Pumping Water Level 14.8 • -
THE LOCATION OF THE PROPOSED WELL MUST BE SHOWN AND THE AREA TO BE
IRRIGATED MUST BE SHADED OR CROSS-HATCHED ON THE DIAGRAM BELOW -.
• This diagram represents nine (9) sections. Use the CENTER SQUARE
(one section) to indicate the location of the well, if possible.
-*---1 Mile
I 1 - , f 1 ,
• + - + - + - + - + - +
I 1 I I I
- + - + - + - + - + - + -
NORTH SECTION LINE
r Kr I I
- + - + , 1 + — + -
N z z
A i I H
CIV o I Ci
W ta In 2
w
• - + - + El
Ei
+ - -f
I SOUTH SECTION LIlTVE I {
- + — + — + — + — + — + -
I - I i I I - i
- -1- — + — + — + + — +
I I I I I f
THE SCALE OF THE DIAGRAM IS TWO INCHES EQUALS ONE-MILE
Owner of Number of acres
irrigated land to be irrigated _
Legal description of
irrigated land
WATER EQUIVALENTS TABLE (Rounded Figures)
5acre-foot covers 1 acre of land 1 foot deep.
1 cubic foot per second (cfs) . . .. 449 gallons per minute
1 acre-foot ... . 43,560 cubic feet ... . 325,900 gallons.
1,000 gpm pumped continuously for one day produces 4.42 acre-feet.
100 gpm pumped continuously for one year produces 160 acre-feet.
i
PUMP INSTALLATION REPORT •� :H.e
Py�p Make Fitt Bite - z
• CID ' .
Y1, ° 5�
Type Sub. R
Slot �'
Powered by • HP 3 ; ` i
y, 23 .
Pump Serial No. liniment ,{;. .
'i;. ,`l J C J WATER
Motor Serial No. Unba � �� TABLE
Date Installed May 30.-1.972 ; r J
rc to
Pump Intake Depth 153ft: -4 ,A a
-
Remarks _ ?'; . ., t
a' .'
1. •7
&1::..0
d
g
•• '•I �'.
• _. _... •S
W /
t ...
L
WELL TEST DATA WITH PERMANENT PUMP a I'° `• i
Date Tested May 30 1972 = a; ?r. ..PN a ri
FiiiO. Z
.'7 DEPRESSION
Static Water Level Prior to Test 91 0 i
•
24 .. .„ .. •
�th of Test Hours
Sustained yield (Metered) 15 GPM .1
Pumping Water Level 148
Remarks u
sr e'
cs
CONTRACTORS STATEMENT
The undersigned, being duly sworn upon oath, deposes and says that he is the contractor of the well or
pump installation described-hereon; that he has read the statement made hereon; knows the content
thereof, and that the s true of his n knowledge.
Signature _ License No. S e
/
State of Colorado, County of ' .14 .2 SS
Subscribed and sworn to before me this L.I$, day of 19 V .
• MyC6mrtistion ex ires: — el
' �� — , 19 . •
Notary Public Au V (22,121
FORM TO RE MADE OUT IN QUADRUPLICATE: WHITE FORM must be an original coPY on both sides and signed. I
WHITE AND GREEN copies must be filed with the State Engineer.PINK COPY is for the Owner and YELLOW COPY is for the Driller.
• • 1.
WRJ-5 7,16AX C101 Columbine
, 845 Sherman Street,N OF R De RESOURCESColorado 80203 ry03, 14 "6>q
TYPE OR PRINT IN BLACK INK. APPLICATION MUST BE COMPLETED BEFORE ACCEPTANCE. tio
FEBFEgt972 i
w RECEIVED
firICATION FOR: GROUND WATER TO BE USED FOR: WATER Wgsgaug FS w
A PERMIT TO USE GROUND WATER X DOMESTIC (1) \S`'SSOWERelita
,)( A PERMIT TO CONSTRUCT A WELL LIVESTOCK (2) `4 ill • )
REPLACEMENT FOR NO. MUNICIPAL (8) 8 (6)
X A PERMIT TO INSTALL A PUMP OTHER
OTHER
WELL LOCATION
APPLICANT A ,ry9j, t//w 6� COUNTY f iEz d
Street Address /97-/ /Jox5G/S 44:1WC 4 of the 7,f * of Section /2_
City & State Col'2/Orf,ERP,G 4't�/ eerie real, T. _illy , R.,�-% {9/ (9 P.M.
IN ADDITION TO THE ABOVE, THE WELL MUST BE
Telephone No. 1:9— O22 P LOCATED WITH REFERENCE TO GOVERNMENT SURVEY
NAME OF AQUIFER GROUND WATER IS TO BE OBTAINED CORNERS, MONUMENTS OR SECTION LINES BY DISTANCI
AND BEARING (DOMESTIC WETJN MAY BE LOCATED BY
FROM: /41T/ > - ho E LOT, BLOCK, & SUBDIVISION.)
PROPOSED TOTAL DEPTH OF WELL fed Ft. 440 ft. from oRth section lii
forth or South)
ESTIMATED MAXIMUM PUMPING RATE At" /J"D ft. from asiateria CT-Section lii
(East or West)
AVERAGE ANNUAL AMOUNT OF GROUND WATER TO BE
LOT BLOCK FILING #
APPROPRIATED Acre-feet
SUBDIVISION
IIIIECIPATED GROUT PROGRAM n .
/� Ground Water Basin P.1,4� /)' !i, R
e
Material (, E yy/4"yj7"
Water Mgnnt. Dist.
Intervals toff RO 7-1`a yrt
Anticipated drilling date .2 —/5^ 1921
Placement Method /4,04 X: //I LIA?Tn-71 Owner of land on which well
is located:
PROPOSED CASING: n r/1/ &1-d/` i47
Plain yL in. from es ft. to yo O ft. Other water rights on this Lando/co/ E
in. from ft. to ft.
Perf. in. from ft. to ft.
ng_/ryl in. fromoA,,,?/,QF'ft. to ft.
Driller N /Ail L/I'A71 A/4 No. VCti" .El, ,j ' a7 vile
Signature of� pntl!'/
Address BOX l,(// rt g' C6 / C (� �Q�/
IF WELL IS USED FOR �IGATION, BACK SIDE OF THIS APPLICATION MUST BE COMPLETED. "`V.�
FOR OFFICE USE ONLY
CONDITIONS OF APPROVAL APPLICATION APPROVED: VALID FOR ONE (1) YEAR
AFTER DATE ISSUED UNLESS EXTENDED FOR GOOD
CAUSE SHOWN TO THE ISSUING AGENCY.
PERMIT NO. 50954
• DATE ISSUED FEB 2 1972
STATE ENGINE 'r-
BY r ��
0
• WATER SUPPLY INFORMATION SUMMARY
Section 30-28-133,Id1, C.R.S. requires that the applicant submit to the County,-Adequate evidence that a water supply that
• is sufficient in terms of quantity, quality and dependability will be available to ensure an adequate supply of water.
1. NAME OF DEVELOPMENT AS PROPOSED
C,��t, et- CAS NC ( om
2. LAND USE ACTION UC,'n co,/ .4y0[-k Q(M L: ✓1 (1 (ri.,t, , ( e t 3
3. NAME OF EXISTING PARCEL AS RECORDED
SUBDIVISION FILING BLOCK LOT
4. TOTAL ACREAGE 7 02 5. NUMBER OF LOTS PROPOSED p PLAT MAP ENCLOSED 0 YES
8. PARCEL HISTORY - Please attach copies of deeds, plats or other evidence or documentation.
A. Was parcel recorded with county prior to June 1, 1972? 0 YES fP NO J
B. Has the parcel ever been part of a division of land action since June 1, 1972? 1 YES 0 NO
If yes, describe the previous action Ee-OPO1D (..-5)4:M1'CrnbN
7. LOCATION OF PARCEL- Include a map deliniating the project area and tie to a section corner.
He 1/4 OF NE 1/4 SECTION I 7- TOWNSHIP I 1244 0 S RANGE o ` 0 E grew
PRINCIPAL MERIDIAN: Z'iTH ,YfIt.M. 0 UTE 0 COSTILLA
a8. PLAT- Location of all wells on prop y must be plotted and permit numbers provided.
Surveyors plat 0 Yes No If not, scaled hand drawn sketch Z(Yes ❑ No
9. ESTIMATED WATER REQUIREMENTS - Gallons per Day or Acre Feet per Year 10. WATER SUPPLY SOURCE
;2:I/EXISTING 0 DEVELOPED 0 NEW WELLS -
WELLS SPRING PROPOSER AQUFms•(CHECK ONE
HOUSEHOLD USE # of units GPO AF WELL PERMIT NUMBERS o MENIAL ❑UPPER ARAPAHOE
(i�'Is4. 0 UPPER oAwsaw ❑LOWER ARAPAHOE
0\ COMMERCIAL USE # of S.F. GPO AF o toeme w 0 DAMwE FOX HILLS
AKOTA
0 orMER
IRRIGATION 1< of acres GPO AF
STOCK WATERING q of head GPD AF 0 MUNICIPAL
❑ ASSOCIATION WATER COURT DECREE CASE NO.'S
OTHER - GPD AF 0 COMPANY
❑ DISTRICT
TOTAL GPD AF NAME
LETTER OF COMMITMENT FOR
SERVICE 0 YES 0 NO
11. ENGINEER'S WATER SUPPLY REPORT 0 YES VINO IF YES, PLEASE FORWARD WITH THIS FORM. This may be required before our review is completed.)
12. TYPE OF SEWAGE DISPOSAL SYSTEM
ASEPTIC TANK/LEACH FIELD 0 CENTRAL SYSTEM • DISTRICT NAME
LAGOON 0 VAULT • LOCATION SEWAGE HAULED TO
❑ ENGINEERED SYSTEM (Attach e copy of engineering design) ❑ OTHER
Hello