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for
Septic Permits
Permit # GI 9722139
Permit Type: Health / EHS History I EHS Conversion History
Situs Street Address 16876 LONGS PEAK RD
Situs City, State, Zip
Sec/Town/Range: 14 -06N -66W Application Status: Finaled
Application Date: 03/11/1996
Parcel # (12 digits)
Owner Full Name:
Owner Address:
Contact Name:
Contact Address:
080514403001-R1326086
THAYER RICHARD
RT. 2
LUCERNE,CO 80646
Owner Phone #: 303 3535555
Contact Phone#
Information above has been Verified in Accela by employee noted below
x April 07, 2009
Processed by: Date
Report ID: EHS00024v003 Page 1 of 1
Print Date -Time: 4/7/2009 10:19:28AM
WELD COUNTY HEALTH .DEPARTMENT
1555 17th Ave.
Greeley, Colorado
Application for Permit to Install, Construct, Alter or Repa' ndividual Sewage Disposal System.
Owner .-,Sp or A ss Phone
£t ______
Addr9 of Sitecf, /7L4, 5 ' S'1
Mailing Address*'
General Information Septic Tank
1.. Living Units 1. Liquid Capacity !/t xf.) Gallons
2. No. of Bedrooms 2. Dimensions �W L D
3. No. of Baths 3. Material
4. Basement Drain 4. Type Inlet
5. Automatic Dishwasher Type Outlet
6. Garbage Disposal
7. Automatic Laundry Seco a T eatment
8. Size of Lot
9. Type of Soil Field Ied
10. Percolation Test
11, Water Supply Gr 1. No. of distribution lines
12. Lot Grade 2. Trench: Width Length
3. Type Filler Material
13. Water Table Depth �
14. Other'iarZ'
4. Depth of Filler Mate
5. Gravel Size j"d_�
Type Tile
��`/ �,.�� �4 6. 7. Depth of Cover _,?,
8. Other
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 with1 Regulation No. 1 of the Weld County Health De-
partment. l/ -
Date: / 7 ! Applicant • /` r�_r#� .'x -f •.
The plans and specifications as shown are approved, pending payment of p rmit
Sanitarian :
Date: /&/'_2
The above systerr��inspectec1 an fou co ly with the pin and description.
Installed by
PERMIT FEE
Received by
Please use reverse side
Plan or use
sheet of paper.
Date:
Date _. / —/:::: -f
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