HomeMy WebLinkAbout20241361.tiffScanning Cover Sheet
for
Septic Permits
Permit #
Permit Type:
Situs Street Address
Situs City, State, Zip
SE -0400115
Health / Residential / Statement of Existing
1308 E 20 ST ti
Sec/Town/Range: 15 -05N -65W
Parcel # (12 digits) 096115200001-R3389986
Owner Full Name:
Owner Address:
Contact Name:
Contact Address:
ELLIOTT SHAWN
1422 8 AVE
GREELEY,CO 80631
ELLIOTT SHAWN
1308 E 20 ST
GREELEY, CO, 80631
Application Status: RECORDED
Application Date: 09/27/2004
Owner Phone #:
Contact Phone# 970-304-0383
Information above has been Verified in Accela by employee noted below
September 30, 2008
Report ID: EHS00024v003 Page 1 of 1
Print Date -Time: 9/30/2008 12:51:15PM
WELD COUNTY DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT
1555 NORTH 17TH AVENUE
GREELEY, COLORADO 80631
PHONE (970) 304-6415 FAX (970) 304-6411
STATEMENT OF EXISTING SEPTIC PERMIT
Permit #: SE -0400115 Sec/Twn/Rng: 15 05 65 PERMIT
Owner: ELLIOTT DONALD A Applied: 09/27/2004
Applicant: ELLIOTT SHAWN
Parcel #: 0961-15-2-00-001
Location: 1308 E 20 STREET
Legal Desc: 12444 W2 L3 NW4NW4 1 5 5 65 %1308 E 20 ST % •
Description: HOUSE
Commercial: N Residential: Y Acres: 5
# of Persons: 4 Basement Plumbing: N
# of Bedrooms: 2 Bathrooms - (Full): 2 (3/4): 0 (1/2): 0
Water Public: Y Water Source: GREELEY
Water Private: N Cistern: N Well: N Well Permit Number:
Septic Tank: 1250
Absorption Trench: UNK
Absorption Bed: UNK
sq. ft.
sq. ft.
Tank Material: CONCRETE
Year Installed: UNK
NOTICE
The property owner/agent has certified by Notary Seal that the above described septic system is in fact installed as described, and
'sts at this time on the parcel identified above by the parcel number and/or le •.. _ cription, and further states that the system
IS S NOT in good working order and to the best of his/her knowledge IS IS NOT ailing to function properly.
The property owner/agent further understands that any falsification or misrepresentation may result in the revocation of any permit
granted based upon this information hereby submitted and in legal action for perjury as provided by law.
The Statement of Existing Record relies on information the property owner or his/her representative . • ides, under oath, indicating
current status of the system and representing to the best of his/her knowledge that the system IS S NO failing to function properly.
Issuance of the Statement of Existing Permit for any system does not constitute assumption that the site was evaluated or inspected
during any phase of construction by this Department to meet regulations.
x
C
En Envuionm6ntal Health Specialist Date
Form: S_EXIST
Wi40%;
�DcCOLORADO
WELD COUNTY DEPARTMENT OF PUBLIC
HEALTH AND ENVIRONMENT
1555 N. 17Th AVENUE
GREELEY, COLORADO 80631
PHONE: (970) 304-6415
FAX: (970) 304-6411
soE# - Oq nC ► (S
ORG PERMIT #
REPAIR #
LOAN #
ISDS # p q 01' 1 •
STATEMENT OF EXISTING FOR SEPTIC SYSTEM
(PLEASE FILL OUT IN BLACK INK ONLY)
PARCEL NO. O 1 le 1152_ cowl.
PROPERTY OWNER SI.tcc w t 1(.`i, P
MAILING ADDRESS 13 c -F 2 0 4
PHONE NO. (1? 30(1•.03 v3
G� 4, fir`
City
rd la .170L31
State Zip
DESCRIPTION OF BUILDING (ex. house, mobile/modular home, shop, office) 120- G 6 C_
3o�' 2 s Coverte cola
oPc,d1) 0 /SW If'9 RI. ec1:ti )s State , zip
LEGAL DESCRIPTION PT __ PT SECTION TOWNSHIPS" ti RANGE Gs' tid
SITE/LOCATION ADDRESS
ed-63c
SUBDIVISION t. awd s >g J ► e Ulm ,�o �• LOT BLOCK FILING
CENCUS TRACT 7-02- LOT SIZE/ACRES `' o �~R 01
COMMERCIAL YES /
NUMBER OF PERSONS Y
BEDROOMS_
WATER SUPPLY - PUBLIC
PRIVATE
RESIDENTIAL NO
BASEMENT PLUMBING YES /
BATHROOMS - FULL Z 3/4 1/2
NAMEGYr-tft/
WELL YES CISTERN YES/NO WELL/CISTERN#
SYSTEM SIZE: Septic tank material is constructed of co , c et and bas gallons capacity.
FIELD: Trench pi h•cc vs square feet or Bed FAk lti'u-c ki square feet YEAR INSTALLED M L.:a.1
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 thistime on the parcel of ground identified by the above legal d ription and -further states
that the system is not in good working order and to the best of his/her knowledge is is no failing to function properly.
I furtller 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.
9. 71-45Cf
DATE
Subscribed_ and sworn to before me this
By
Wit ess my hand and official seaL
DATE
• OWNER SIGNA
n� 74 day of
,2001,
Mycommissign,}expires
NOTARY PUBLIC
0
STATEMENT OF EXISTING INSPECTED & REVIEWED BY
ENVIRONMENTAL HEALTH SPECIALIST
/102z.
DATE
ui[y of ureeiey
;,,,,,r , Water & Sewer
P.O. Box 1928
reel ey Greeley, CO 80632-1928
statement ot Account tor Utility Service(s)
THIS BILL SHOWS A PREVIOUS AMOUNT DUE.
PLEASE REMIT AT EARLIEST CONVENIENCE. IF
PYMT HAS BEEN MADE, THANK YOU.
Account Number 062-769797-01
Service 1308 E 20TH ST
Location
Meter ID Date Curr Read Date Prey Read Usage
09216148 01/02 1824 12/01 1816 8
(Usage in thousand gallons)
1,1 ii itillii
Jan Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Used
Water Budget
Register for WaterSmart. It's free! Track water use & receive
leak alerts Go to greeley.watersmart.com
Registrese en WaterSmart. iEs gratis! Mida el use del agua y
reciba alertas de fuga de agua Visite greeley.watersmart.com
ai ai m
cflma
01
01
RESIDENTIAL WATER Used Rate Amount
Residential Water
8 11.66 $93.28
Base Charge $18.93
Bal Fwd $63.98
RESIDENTIAL WATER $112.21
CURRENT CHARGES
$112.21
TOTAL DUE ON 01/22/24
$176.19
****SEWER CEILING WILL BE SET
FROM YOUR JAN TO FEB USAGE
CUSTOMER SERVICE: 970-350-9811
TO PAY YOUR BILL ONLINE WITH NO FEES, GO TO
WWW.GREELEYGOV.COM/UTILITYBILL
PARA PAGAR SU FACTURA SIN CARGOS, VAYA A:
WWW.GREELEYGOV.COM/UTILITYBI LL
•
Hello