HomeMy WebLinkAbout20062663.tiff 03/29/2006 16: 17 TEL 3036599602 PEService a PESales ipJ 00z/000
aWri MAR 1 5 2006
CENTRAL WELD COUNTY WATER DISTRICT
March 10,2006
•
Fusaro LLC
PO Box 192
Fort Lupton,CO 80621
RE: Cost of Water Service for 21141-25 Frontage Road
Dear Fusaro,LLC:
This letter is in response to your request for water service to serve the following property described as
follows:
Lot 4 of Althen Boyer Subdivision, Part SW'A Section 4,Township 1 North,Range 68 West of the 6th P.M.,
Weld County,Colorado.
Water service can be made available to the above described property. Submitted herewith is the cost for one
5/8"tap at 21141-25 Frontage Road:
5/8"Tap Fee $17.500,00
TOTAL DUE $17,500.00
Upon receipt of the above "Total Due" and the appropriate documentation being signed in the District's
office by all deed holders, the District will prepare a work order for the installation of the meter set. The
District requires a 30 day notice for a tap installation.The cost estimate and availability of service is good for
30 days. Please note that you are responsible for confirming that this property has met the requirements of
Northern Colorado Water Conservancy District and the Bureau. Central Weld cannot issue a tap until all
requirements arc satisfied.
The District will not notify, by separate letter, any prospective landowners or land purchasers of tap fee or
line extension cost increases. Pursuant to District policy, the Tap Fee and/or Capital Improvement Fee will
have to be paid in advance to the District by the prospective customer.
It k your responsibility in confirm with your local Fire Protection Authority if fire flow water capacity is
required for your project. The above cost is for a water service tap only and does not reflect fire flow water
capacity.
If you have any questions regarding the above,please contact this office.
Sincerely,
CENTRAL WELD COUNTY WATER DISTRICT
n W.7. ,Gen; Manager
JWZ/ja
2235 2nd Avenue • Greeley,Colorado 8053 • Phone(970)352-1284 • Fax(970)353-5865
John W.Zadel,General Manager
2006-2663
UJ/Gy/CVUU Ili: If ItL JU:iUJSBU'L rtservice a rtsaies IQ uu:i/uutt
•� OF" DATE (,272 Snit K:2:��(0 No. 675315
M HCCEIVED FROM�LL ift $
W Ziantail .s� Alij..C.4 1,0 AS
t; .T :- '}ir , OFUR RENT 0_4 L.is/�.. yelp µ - .�
!:.:t V FOR (((//1
'° '! ACCOUNT OCASH
J: .. W FROM TO_,.
'Y i• PAYMENT HECK
. ':v ....j_ MONEY
BAL.DUE ORDER Y BY
O 8....
,AF �.� 1182
03/23/2006 16: 17 TEL 3036599602 PEService 8 PESales Vb004/006
PETITION FOR INCLUSION
STATE OF COLORADO )
)ss
• COUNTY OF WELD
CENTRAL WELD COUNTY WATER DISTRICT
'1'O: THF. BOARD OF DIRECTORS OF THE CENTRAL WELD COUNTY WATER
DISTRICT
1/we,being all of the owners of the below described real property, which property is capable
of being served with the facilities of the aforesaid District hereby petition the Board of Directors of
said Central Weld Cotuuy Water District to include the below described real property within the
boundaries of said District.
Assent to the inclusion of such property is hereby given by the below signers, which signers
constitute all of the fee owners of said below described property.
Lot 4 of Althea Boyer Subdivision, Part SW '/, Section 4, Township 1 North, Range 68
West of the 6'h Y.M.,Weld County,Colorado.
Dated this c�� day of /l 4rcL , 20 O CU .
Fus ,L . '
STATE OF COLORADO )
)ss
COUNTY OF WELD ) n '
The foregoing Petition was acknowledged before me this �/d/a1y o1'JP211kOL/
u
20 n.0 , by ki0Ae� Fe Rees be aloft Lt.�-i
Witness my hand and official seal,
Notary Public
My commission expires!
AY COMMISSION EXPIRES; 11/15/2006 `.`C
I JODI L.tb, 't
l WILSON I
14c1^ CO.
u3/28/2000 18:18 ILL 'J038588802 PEService 8 PESales ®005/008
Revised 4/30/96
ACTIVE TAP
TAP FEE AGREEMENT
THIS AGREEMENT,made and entered into this day of ,20
by and between the CENTRA1.WELD COUNTY WATER DISTRICT,hereinafter cal led the District,and
Fusaro.LTC hereinafter called Customer, WITNF.SSETH:
WHEREAS, District has been organized as a legal body and is known as the Central Weld County
Water District,and
WiIERF.AS,Customers are taxpaying electors within said District,or desiring to join said District,or
and,
WHEREAS,Customers are desirous of acquiring one water tap of 5/8 inches in diameter from
the said District,
NOW, THEREFORE,in consideration of the premises and the terms of this agreement,it is mutually
agreed as follows:
1. Customer agrees to pay the tap fee of$ 17.500,00
Seventeen Thousand Five Hundred and no/100 Dollars.
2. The description of the premises for which this tap is being purchased is as follows:
Lot 4 of Althen Boyer Subdivision,Part SW Y.Section 4,Township 1 North,Range 68 West of the
6°P.M.,Weld County,Colorado.
3. This agreement,when approved by the Board of Directors,shall become a legal and binding contract
upon all parties hereto.
4. Customer further agrees to execute any and all easements needed by District at no expense to
District, across Customer's property for the purpose of installing the District's service line and meter pit
constructed by District. District shall be responsible for restoring surface area back to reasonable condition
at District cost.
5. It is further mutually agreed that this agreement shall extend to and be binding upon the heirs,
executors,administrators and assigns of the parties hereto-
6. Customer further agrees to the following special provisions:
• N/A
7. Customer further agrees to abide by the rates established and the mks and regulations of the District.
IN WITNESS WHEREOF,the parties hereto have hereunto and hereunder set their signatures the day
and year first hereinabove written.
CUSTOMER SIGNATURE CENTRAL WELD COUNTY WATER DISTRICT
(Property Owner)
HY
Fusaro,LLC
ATTEST
:517o£t'..•
a. a `• cs_ a ,o�5t213k�q�s
_ells v,FJ STATE OF COLORADO _i `
ISION OF WATER RESOURCES : ' n. �j
OFFICE OF THE STATE ENGINEER el ,--------
57'Su a a i.JUL 1971 cf.,'
,"
.C.e ineelo,Se ; HAN RE,Vf0 -
Yield P AND STATEMENT FOR WATER WELL FILIN/� f} srAtE FMo QR s
Checked.By t ,'ti CWC�_7° `Jr, Co
PERMIT NUMBER -, l62gZ1Z9Z;I
Gv• TBHq ' 151'744-F WELL LOCATION
STATE OF COLORADO ) SS 67L'
CLAIMANT (s) Aitken aid Beyer Weld County
SW ti of a %. sec 23
being duly sworn upon oath deposes and says that he (they) is (are)
the owner(s) of the well described hereon; the total number of acres T IN R 68 W 6 P
of land irrigated from this well is N3Ae INDICATE WELL LOCATION ON DIAGRAM
work was commenced on this well by actual construction on tho
NORTH
4th day of November 19 ; the sustained
I i i
I I I
yield from said well is 12_gpm,for which claim is hereby made I I I
1
for Domestic and Industrial purpose le);
I l I
. I I
the average annual amount to be diverted is 20M --_—L---I --- —_I --Tr
, r �
acre-feet; this map and statement is filed in compliance with law; i I I 4 in
he(they) has (have) read the statements made hereon; knows the I I 1
content thereof; and that the same are true of his(their) own ___1— __L_ L__
knowledge. r r���,�- I I I
Aa lui l a. I I I
Signature (s ti i
I I
•
Address:
836 Nast 17th Avenge SOUTH
12411-tri. Colorado 80218 WELL SHALL BE LOCATED WITH REFERENCE TO
GOVERNMENT SURVEY CORNERS OR MONUMENTS,
d-end carom to before me on this /J, day OR SECTION LINES BY DISTANCE AND BEARING.
:•Sub$Cribe
v7
of 19 '/ 225 ft. from South section line.
(North or South)
•
My Comittissimrekpires:. IMyCsourilerloxexplretApr. a,in
�SaaU 290 ft, from West section line,
el,1�. i7 -tere, .a���.F� • (East or West)
leg
ry Public
Ground Water Basin
•
WELL DATA Water Management
District
•
' Date Completed April 13th/1956 Domestic wells may be located by the following:
Static Water Level 275 feet LOT , BLOCK
Total Depth of Well 680 feet SUBDIVISION _
FILING #
ACCEPTED
C CFOR FILIINGG IN THE OFFICE OF THE STATE ENGINEERROOFCCOO ORADO ON THIS 19 DAY
dr
at. - , 1921, Cam!• ' .L -L.
((�J ST E INEER
• FORM TO BE MADE OUT IN QUADRUPLICATE: WHITE FORM must be en original copy on both sides and signed.
WHITE AND GREEN copies must be filed with the State Engineer within 30 days after the well Is completed or within 7 days
after expiration date of the permit,whichever is sooner; PINK COPY is for the Owner and YELLOW COPY is far the Driller.
WRa-5;as;.•._ DIVISION C. LATER RESOURCES, DEPARTMENT OF N RAL RESOURCES
lot Columbinc Bldg., 1045 Sherman Slreet, Denver, Colorado 80203
y Q A PERMIT TO USE GROUND WATER r—"'"Nteet.ogn3.?QL-7 A PERMIT TO CONSTRUCT A WELL APPLICATION FOR: . REPLACEMENT FOR NO. OW0B-706 4 �� �
hL_1 A PERMIT TO INSTALL A PUMP !.Anti, tti• I �J OTHER •; a'
PRINT OR TYPE LOCATION OR;rWELC{,
APPLICANT Althen land Boyer COUNTY Weld e)i 4 r.,u�"
` \611;• ''
Street Address 836 L. 17th Ave. • 8111 4, of the ell . ), sec, 23
City & State Denver,: Colorado 80218 T. 1 N , R, 68 W , 6 P.M.
Street or
Use'of ground water Borestie & Industrial Lot & Block
Owner of land on which well ,City or
is located Althea .and Boyer Subdiv. Filing
( Owner of irrigated None land Not irrigated by well Ground Water Basin
Number of acres Water Management None
to be irrigated District
Legal description. of - . ' •
irrigated land LOCATE WELL ON THE BACK OF THIS SHEET
• • Driller George Waneka No. 2
Other water rights on • Driller 's
this land Address
Aquifer (s ground water is to be obtained
from 485 to 680 ft. /tr.r� - C/'✓ c cfr?:i-r;."-
Signatu a of Applicant /
Storage capacity • NTotie AF rONDIT.I.ON5_OF_.APPROVAL. ,,,,-
ANTICIPATED PUMPING RATE• 12 GPM
r • GE ANNUAL AMOUNT OF GROUND WATER TO
PROPRIATED 20 Acre-feet
• TED WELL DATA
. ated start of drilling Summer 19 71
II a• ated start of use 19 y��``py •
.
W��yy
meter: O 17r1P iO2
in. from 0 ft. to 485 ft. APPLICATION APPROVED:
in. from 485 ft. to —680 ft. VALID FOR ONE 0) YEAR AFTER DATE ISSUED.
UNLESS EXTENDED FOR GOOD CAUSE SHOWN TO
THE ISSUING AGENCY
. e
lain 6 in. from 0 ft. to 485ft. .. PERMIT NO, CONDITIONAL L /
4* in. from 485 fu.. to bUOft.
DATE ISSUED
Perf. 6 in. from 0 ft. to 4.85ft, •
4 in. from 485 ft. to -6S0ft.
- STATE ENGINEER
ESTIMATED PUMP DATA .
• - Outlet BY
Type electric HP 5 size 1
APPLICATION MUST BE COMPLETED SATISFACTORILY BEFORE ACCEPTANCE (OVER)
— . _..-. .----. -- - ---�O1N213i¢ —1
?,3. y ,� ,
Whjoy-69 Y•, DIVISION OF RATER RESOURCES, DEPARTMENT OF NA1..dAL RESOURCES es, 'it
101 Columbine Bldg., 1845 Sherman Street, Denver, Colorado 80203 (,aj a (/(1977fo
i• col r-7 A PERMIT TO USE GROUND WATER a �Z2�3 y� , qE'Ike v
'" / / A PERMIT TO CONSTRUCT A WELL it Z02 ea,�
APPLICATION FOR: t7 REPLACEMENT FOR NO. CNCD 706-15 .� ttkti ,oNCEes ,`�+
£ A PERMIT TO INSTALL A PUMP 1, ,4t, y ,zcZro2�j�
/--/ OTHER „y) w
PRINT OR TYPE "� LOCATION 0liaP1,r£�fh',:`y' :.S
APPLICANT Althen and Boyer COUNTY Weld N/„., a
_ 95'
Street Address 836 Sa. 17th Ave. SW ,' of the SW 4, sec. 23
City & State Denver, Colorado 80218 T. 1 N , R. 68 W , 6 P.M.
Street Or
Use of ground waterlbmestic & Industrial Lot & Block
Owner of land on which well City or
is located Althen and Boyer Subdly, Filing
Owner of irrigated ifetria ..
land Not irrigated by well Ground Water" Basin
Number of acres Water Management
to be irrigated District None
Legal description of
irrigated land LOCATE WELL ON THE BACK OF THIS SHEET
Driller George Waneka No. 2
Other water rights on Driller's
this land Address p�
Aquifer m ( ground ater is to be obtained � � data_ /� - / ' /
from p). to 68w0 er
Signatu a of Applicant
Storage capacity NoX.e AF cONOITIONS OF APPROVAL
ANTICIPATED PUMPING RATE 12 GPM
I
AVERAGE ANNUAL AMOUNT OF GROUND WATER TO t��.///
BE APPROPRIATED 20 Acre-feet MSS/
ESTIMATED WELL DATA 1)�� �� ( iq
Anticipated start of drilling Summer 19 71
Anticipated start of use n 19
fl
Hole Diameter:
lot.
6 In. from 0 ft. to 485 ft. APPLICATION APPROVED:
4'k in. from 485 ft. to 660 ft. VALID FOR ONE (I) YEAR AFTER DATE ISSUED
UNLESS EXTENDED FOR GOOD CAUSE SHOWN TO
Cal : THE ISSUING AGENCY
c
Plain 6 in. from 0 ft. to 485ft, PERMIT NO. R F- /0/4 CONDITIONAL / 7
---41-- in. from 485 ft. to Oft. DATE ISSUED _ AUG 1 g 1971 .
Pert. 6 in. from 0 ft. to 485ft.
g in. from 465 ft. to 7$Dft, 6 .t J
STAT EN' INEER •
ESTIMATED PUMP DATA
Outlet BY
Type ele ctrl,c HP 5 Size 1.1 _
APPLICATION MUST BE COMPLETED SATISFACTORILY BEFORE ACCEPTANCE (OVER) 0
._1•. •$RS-2s-7 irto,, • STATE OF COLORADO �b 4 '''
f,,,_. DIVISION OF WATER RESOURCES t/A t�
IIndex DWD No. OFFICE OF THE STATE ENGINEER c: N i3f2 ^i
o; wR RCEIIJ v
Completion ' .' L1,n'. spire Rfsckm, 'U
Yield MAP AND STATEMENT FOR WATER WELL FILING •
\°se Cp Q NffR L�4
Checked Sy Si` 15774-.,, .. 62$
- .a., PERMIT NUMBER loot
STATE OF COLORADO I SS WELL LOCATION
Weld County
CLAIMANT(s) Alt.hen and Boyer
SW Aof SW 'A,sec. 23. .
being duly sworn upon oath deposes and says that he(they) is(are) .
the owner(s) of the well described hereon; the total number of acres T 1 N R 68 W . 6 P.M,
of land irrigated from this well is —O— •
INDICATE WELL LOCATION ON DIAGRAM
work was commenced on this well by actual construction on the
4thiltry! April 1956 . the sustained NORTH
days 1 r i •
I I •I
yield from said welI ISs 12 gpm, for which claim is hereby made I i I I f ;
for purpose isl:
domestic and industrial i .
rr ----r' — ..�. �---'I the average annual amount to be diverted is 20 uS - t t r C
acre-feet; this map and statement is filed in compliance with law; I '. .;
1 I. . 1
he(they) has (have) read the statements made hereon; knows the i I I••
content.thereof;.alid„that the fsmnare..true of his(their) own
knowledge, .. i �, ` , I 1 I I .
Signature(s) '91,14:4 N 'er �/"'� —. °
SOUTH
836 Ea. 17th Ave.
Address:
Denver, Colorado 80218 WELL SHALL BE LOCATED WITH REFERENCE TO
_ GOVERNMENT SURVEY CORNERS OR MONUMENTS,
Subscribed rand swam to before me on this r day4selk OR SECTION LINES BY DISTANCE AND BEARING.
of - 19 7 225 ft. from South section Ilne.
• • .. . y,. 1. _ ' - 4^2 -7 ,3 (North « South)
My Commission expiresti.;4 : :;
(Seal) P 290 ft. from West section line.
(East or West)
• r' Notary Public None
• Ground Water Basin
WELL DATA Water Management None
District
Date Completed Nov. 5, 1971 Domestic wells may be located by the following:
Static Water-Level 275 ft. LOT -- , BLOCK
Total 680 ft. SUBDIVISION
Depth of Well
FILING ft CWCB-706
ACCEPTED FOR FILING IN THE OFFICE OF THE STATE ENGINEER OF COLORADO ON THIS DAY
OF , 19_._.
STATE ENGINEER
FORM TO RE MADE OUT IN QUADRUPLICATE: WHITE FORM must be an original copy on both sides and signed.
WHITE AND GREEN copies must be filed with the State Engineer within 30 days atter the well is completed or within 7 days
after expiration date of the permit,whichever is sooner;PINK COPY Is for the Owner and YELLOW COPY is for the Driller.
OCT-31-2002 04 :20 PM HEr*"F_R 30368487041`
•
. ■! 0. r. Cottle
ooxn ►.ovs , .. sat.ssoteeee
Governor
LSL
DIVISION OF WATER RESOURCES
plaDepartment of Natural'Resoureos
,' Mart A) v 300 Columbine Building
1845 Sherman Street
Denver, Colorado 80203
G ''77~ba35 April30, 1974
r;jektitr- ifittkw,"
er
Ms . Carol Lee, Zoning Administrator
Weld County Planning Commission
County Services Building
Greeley, Colorado 80631
Re: Althen - Boyer
Commercial Park Re-Zoning
Dear Ms. Lee:
This is to acknowledge receipt of additional information concerning
the water supply plan for the above referenced Commercial Park. The
developers have a commercial well (Permit No.• 015774-F) which is capable
of providing approximately 17,000 gallons per�•ay with adequate storage. ,
The developers intend to limit the amount of water available to each trpct
to not more than 1,000 gallons per day. This appears reasonable if the
potential purchaser does not require considerable water and does not
desire lawns or green belts .
I trust that this opinion will be useful to Weld County with respect
to re-zoning, If you have further questions , please feel free to contact me.
Very truly yours,
•
. I per 5
Stet Engines �8y
tg1A
tv 1p`1 t
CHOAD:mvg ^, n1
' co: W. Wilkinson, Div. Eng.
Reiner Haubold 'Pet *Ott'
HSP1 06P APPLICATION FOR INI)]:V:I:I)(JAL. SEWAGE DISPOSAL SYSTEM NO. G•"•89027
WELD COUNTY HEALTH DEPARTMENT REPAIR APPL.ICAT]:Ci
ENVIRONMENTAL HEALTH SERVICES
1516 HCJSPITAL. ROAD, GREELE Y, CO 80631
353-0635 I_XT-.2225
OWNER D:I.RKSEN, LARRY E. ADDRESS 4945 VIA PAPEI... PH ( 61 9) 587-117
S A N DIEGO CA 92122
ADDRESS OF F'F.1JlOSEI) SYS"TE"M ::''.114 :I:-25 FRONTAGE ROAD
ERIE CO 80516
LEGAL DESCRIPTION OF SITE:: : SEC 23 TWF' 1 RN(:: 68
SUBDIVISION :: AL THEN N I:;OYI_.R LOT 4 BLOCK i FILING 0
USE TYPE : COMMERCIAL... 0760078 ON FILE
SERVICES : PERSONS 9 BATHROOMS 1 .00 0 LOT SIZE 2. 61 ACRES
BEDROOMS 0 BASEMENT PLUMBING NO WATER SUPPLY PWE::I_t..
APPLICANT ACKNOWLEDGES THAT THI::: COMPLETENESS OF THIS APPLICATION IS C:ONDI:TIONAL.
UPON FURTHER MANDATORY AND ADDITIONAL. TESTS AND REPORTS AS MAY BE:: RE:(,(J:[REI) BY THE
WELD COUNTY HEALTH H DEPARTMENT TO Dl MADE:: AND FURNISHED BY THE APPLICANT OR BY THE
('JEL..Ii COUNTY HEALTH DEPARTMENT FOR PURPOSES OF THE EVALUATION OF THE:: APPLICATION;
AND THE ISSUANCE OF THE PERMIT IS SUBJECT TO SUCH TERMS AND CONDITIONS AS DEEMED
NECESSARY S'ARY TO INSURE COMPLIANCE WITH RULES AND REGULATIONS ADOPTED UNDER ARTICLE
0 , TITLE 25, CRS i973, AS AMENDED. THE APPLICANT CERTIFIES THAT THE PROPOSED
: YSTI:-iM W:I:I...I_. NOT BE:: LOCATED WITHIN 4()O FEET OF A COMMUNITY Y SEWAGE SYSTEM. THE:
UNDERSIGNED HEREBY CERTIFIES THAT AI...I... STATEMENTS MADE, INFORMATION AND REPORTS
:N1SAMITTED HEREWITH AND REQUIRED TO BE SUBMITTED BY THE APPLICANT ARE, OR W:[L.L. BE: ,
RI:: :::SFNT'E::I) TO BE TRUE:: AND CORRECT TO THE: BEST OF MY KNOWLEDGE AND BELIEF . AND
;ARE DESIGNED GNF:::I',D TO BE:: RELIED ON BY THE WELD COUNTY HEALTH DEPARTMENT IN E::VAL..uAT:I:NG
il"IE. SAME:. FOR PURPOSES OF 1 'SOING THE PERMIT APPLIED FOR HEREIN. I. I"UI':THII l..Ji'JDE:R-
( ND THAT ANY FALSIFICATION OR MISREPRESENTATION MAY RESULT IN THE DENIAL OF THE
APPLICATION OR REVOCATION I:ON OF ANY PERMIT GRANTED BASED UPON SAID Al'F'I...:I:(,ATION AND
FN L.EGAI... ACTION FOR PERJURY AS PROVIDED BY LAW.
APPLICATION L:I:Ct-1T :I:ON FEE 6. 00.00 ..JI_ RY D(:l(.JI._AN ;FR
RE:C ' D BY RECEPTIONIST AID / 8r-
DATE ;11 /14/89 c ?:1: .A1 //. ; ii : DATE
I ^ '
�\f icNo vs-s- WELD COUNTY HEALTH DEPARTMENT
1516 Hospitalto Road
Greeley, ��
Colorado PERMIT NO.
Co `1 Ph. 353-0540 C--3007 r
ewsApplication for permit to Install, Construct, an Individual Sewage Disposal System. �--
Owner .�2I��/J -�� ,,,L, Address o� 70247 3o L Phone %95/ /rW`W/
Direction to site: HwyZc2 Rd. h// N7�rfi. E mirmi., W mi.
/�Legal Description: Ptn ei G!J Sec.02y_, TJ N, laW Subdiv./7��— >11 [/ ,Blk
/717547)., /
4 4,,/,Ax_c( General Information
Q�� Dept. Use Only
No. Bedroom No. Per ons
for c • ..._,
Pfa 9L 0/q Sh Oli / Perc. Rate (Av,`g' of 3) 13: 1..,Cat c t�X.-,
No. Baths Basement Plumbing Soil Type \--x uE, %gull iS± -r
Size of Lot cs O A •5 7O y Hz0 Table Depth
H20supply (if well give depth) .!-'P�� o �Q cci
Lot Grade < z);11T)
IVeW�io�r to Mobile Home Modular Add'n Requires Engineer Design Y o
Type of sewage disposal requested: If yes — reason
Septic tank 'Privy Other •
Comments:
(IInstallation Instructions: (Minimum Requirements)
illtl
Septic Tonic -32:C -I- Is Absorption Trenches IP: � Sq. Ft.
Other or
Seepage bed Sq. Ft.
Special Instructions ��
This system will be constructed and installed in accordance with the above specifications and regulations re-.
garding individual sewage disposal systems in Weld County, Colorado
This permit shall expire at the same time as the building permit, or, if no building permit is issued, the permit
shall expire 120days after its issuance, if construction has not be • c ornrr tc A
Date: -/ etA, - O o?," - 197Z owner-X.:J 4 max^-."`.-� ay ar
Applicant:
The plans and specifications as shown are approved pending payment of miq fee.
Date:'
Sanitarian , sit
a 4-yi., .
The above system ins ected and found to comply with plan and descrip 'on.
Systems Contractor: j t is ,. 2�141J Date:
• l ( Sanit ri
Engineer Review: •
(Date) (Signature)
Permit Fee: $�6 /
Received by: • AAA,I�(.J/ Dote: li/ 7G
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