HomeMy WebLinkAbout20080350.tiff •
• • Tap No. / /2 3
�Q �C LITTLE THOMPSON WATER DISTRICT
• frt. ke' �J Domestic Water Agreement
This Agreement made this g day of GT ,20 0 2-, by and between
Land Owner, Hereinafter referred to as User, and
LITTLE THOMPSON WATER DISTRICT, a statutory water district, herinafter referred to as the District, is upon the
following terms and conditions, for the property and water tap shown below:
Legal Owner of Property: —C re ( 1 / 'l
Street Address of Property: / 7 r2/ 6 (�v _
Town and Zip Code: PiGi-(t eUf lie ao !fib I LTWD Tap No: g/. •---3
Purpose Purpose of Domestic Water Service:
Residential Single Family; Multi-family; Commercial; or Other (describe)
WHEREAS the District is the owner of facilities for the purpose of furnishing Domestic Water to users within said District:and
WHEREAS the user is desirous of obtaining domestic water for his property,
NOW THEREFORE, the parties hereto agree to the following:
1. This agreement shall be the binding contract between the User and the District.
2. User hereby agrees to pay to the District such sum as may be prescribed from time to time by the Board of Directors as the
water rate or charge for such water service. Payments shall start when the District installs the tap and water is available for
delivery. A minimum payment, as prescribed from time to time by the Board of Directors of the District, shall be due and
• payable regardless of water use.
3. Until paid,all rates,tolls,or charges shall constitute a perpetual lien on and against the property served,and any such lien
may be foreclosed in the same manner as provided by the laws of the State of Colorado for the foreclosure of merchanic's lien.
The District shall shut off or discontinue service for account delinquencies or other violations of the District's Rules and
Regulations.
4. No water service may be obtained except upon property included within the boundaries of the District. User agrees to
include the property served within the District,if this has not been previously accomplished.User further agrees that he will
not permit other persons to use water furnished to him under this agreement.
5. District agrees to furnish water to User PROVIDED,that the District shall not be liable for loss to User for failure to deliver
water because of war, riot, insurrection, breaks in the water system or Acts of God. The District shall endeavor to repair all
breaks promptly on District lines.
6. User agrees to abide by such other rules and regulations of the District regarding the use of water as may be established from
time to time by the Board of Directors.
7. The user's name and billing address for all statements and notices is: s..)NM5
Phone: cl10 _ ff3S - 641 IC
IN WITNESS WHEREOF the parties have subscribed their names the day and year first above written.
LITTLE THOMPSON WATER DISTRICT
•
BY: • ,. —C.i
(Signature of Land Owner)
LTWD Form 120 2008-0350
(Rev. April, 1986)
AO ;WES COUNTY HEALTH CTIOR
SOE S 459077
, EN
VIRONMENTAL RONMENNTAL PROT'ECI'ION�VICES Lilt • WAN 9 5'ng 1
1517 16th Avenue Court
ISDS S
Greeley, Colorado 80631 1�¢5dCounevHenhhDeparuneat REPAIRS
(303)353-0635 PE RKET I
• STATEMENT OF EXISTING FOR SEPTIC SYSTEM
�l (PLEASE FILL OUTT�IN BLACK INKONLY) !/
OWNER OF RECORD: S[ E 4 Meiotic (Z35 S�fAIA PHONE: q70 - 3r3 `Sr- 7azqy
MAILING ADDRESS:/ 736,3 W C(L l 5 ei4-REVS ed,E- din 20loS1
)) Q/ City //State Zip
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SITE ADDRESS: / 721 (O Luck_ l 3 ` (nri X w-- l wD /S�J /
c c �/ / City State Zip /
LEGAL DESCRIPTION: PT: S 2 PT:5 7 SECTION: (p TOWNSHIP:3 U RANGE: b-7
SUBDIVISION: LOT: BLOCK: FILING:
NUMBER OF PEOPLE: 3 BATHROOMS: I LOT SIZE: leActeA: BEDROOMS: LITTLE 2_
RESIDENTIAL or COMMERCIAL BASEMENT PLUMBING: Yes I:o WATER SUPPLY: -tt, h w1P5
SYSTEM SIZE: Tank is constructed oleo—hay/41 r and has /MO gallons capacity
(material) / 9
FIELD: Bed sq. ft. or Trench sq. ft. DATE SYSTEM INSTALLED:• l ` ��
8-62O141e, 4/Pt 10-10/C? g 60 cl- &)
on are required to draw a diagram of(eihe sysg 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.
o - 3 / - 9r Ciele-trzik
7 Date Owner
Subscribed and sworn to before me this - ( day of 3t r , 1995 ,
t
by S -✓ S e ee,.-so Id /
Witness my hand and official seal. My commission ex iresk ' COMMISSION EXP S IL 2,'199@'.
7- 3l-is • ,
• Date Notary Public
STATEMENT OF EXISTING REVIEWED BY:
Environmental Protection Specialist
• . S T_
•
BLACK INK ONLY!
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