HomeMy WebLinkAbout20212891.tiffell COLORADO
Division of Water Resources
Dew -trier -it of Natural Resources
ORIGINAL PERMIT APPLICANT(S)
GREEN KENNETH DALE a ALICE T MOORE
WELL PERMIT NUMBER 44275-
RECEIPT NUMBER 9064385
APPR ED WELL LOCATION
Water Division: 1 Water District:
DesignatedBasin: N/A
Management District: N/A
County: WELD
Parcel Name: N/A
Physical Address:
NW 1/4 NE 1/4 Section 7 Township 1.0 N Range 65.0 W Sixth P.M.
UTM COORDINATES Meters k Zone:13 NAD83)
Easth : 525039.1 Nor thing: 4435867.6
See the original well permit file for p runt conditions of approval and additional details, The original permit file can be viewed
using the Well Permit Search Tool at www_water.state.co.us
See Ortgrrnai Permit
Issued By
PERMIT HISTORY
Date issued:
Expiration Date: NIA
12-22-2020 CHANGE IN OWNER NAME/MAILING ADDRESS CHANGED TO CAMILA VANESSA LOP F7
12-22-2020 CHANGE IN OWNER NAME/MAILING ADDRESS. CHANGED TO VOEMNI ORTEGA MARRERO
PrintedC3-04-2021
Fcr me ticns ahoLt this permit call 303.866.3581 or go t` vieww_water.state.co.us 1 of 1
t 0002
WELD COUNTY DEPARTMENT OF PUBLIC SE #y
HEALTH AND ENVIRONMENT
1555 NA NTH AVENUE REPAIR #i
GREELEY, COLORADO 80631 LOAN #
PHONE: (970) 304-6415 ISDS #
FAX: (970) 304-6411
STATEMENT OF EXISTING FOR SEPTIC SYSTEM
THIS DOCUMENT IS NOT SEPTIC PERMIT
PARCEL# \k13OItOOQ3t
PROPERTY OWNER_ LflriL¼4ea PHONE NO. ZIZO ) <ziZ- S
MAILING ADDRESSi l'�l k-►i It Pc Lig�nf CO�'U�Z iSt re Zip
SITE/LOCATIONADDRESS�,*-�i ���t'i� a vie Fray
06
LEGAL DESCRIPTION: PT It))
w+, City "�e State Zip
SECTION 1 TOW1YSHiF �1 RANGE � r `fit
SUBDIVISION ---RI W eke At.1411/4 Loth_ BLocK FILING 04.(041? q•Seitki0A
LOT SI�,E/ACRES.. ALIC5
COMMERCIAL: RESIDENTIAL:
DESCRIPTION OF lH I IL NG AND YEAR BUILT (ex.
itiOwl5L tOp
NUMBER OF PERSONS Zer ' 'NUMBER OF BEDROOMS 1
BATHROOMS FULL 3/4 \ 1/2
WATER SUPPLY: PUBLIC
PRIVATE
house, mobile/modular home, shop, office):
WATE t DISTRICT NAME 044k �.-
WEL ', r► CISTERN YES I NO Permit# {4‘, "'x„75''
Circle which applies: TIER 1 TIER 2 TIER
SYSTEM SIZE AND CONSTRUCTION:
SEPTIC TANK: Septic tank material is constructed of , and has Soo gallons capacity.
FIELD: Trench Sah I i square feet ,or. Bed sq ware feet YEAR INSTALLED,t t% b OW'
Provide a drawing indicating dimensions and location of the existing septic system, including distances from property
lines, easements, dwelling, other lot improvements, water line, water well, surface water features such as ponds,
irrigation ditches, etc. •
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 identified by the above legal description.
I further understand that any falsification or misrepresentation may result in invalid results in determining compliance
with current regulations based upon this information hereby submitted and in legal action for perj ury as provided by
law.
os 1'$ kit
DATE
Subserib td and sworn to before me this
by
r
hr'itness my h' d and official seah
STATEMENT OF EXISTING ACCEPTED BY
OWNER SIGNAT
day of
eat_/
My comml
, 20 in,
Sin (al
0 ICE TECHNICIAN DATE
JURAT
a :
s 3
I
HARD►'' ARL EN RENSHAW
NOTARY PUBLIC - STATE OF COLORADO
NOTARY ID Z02040418 46
MY COMMISSION EXPIRES DEC 1, 2024
r
Place Notary Seal/Stamp Above
Date
SS.
Subscribed and sworn to (or affirmed) before me this
day of
atzie , *2' co?", by
Mond` Year
(7z2 "07:7 sea Q_
Name of Signer No.
Name of Signer No. 2 (if any)
Signature of Notary Public
OPTIONAL
Any Other Required Information
(Residence, Expiration Date, etc.)
This section is required for notarizations performed in Arizona but is optional in other states.
Completing this information con deter alteration of the document or fraudulent reattachment
of this form to an unintended document.
Description of Attached Docume
Title or Type of Documen
Document Date:
Signer(s) Other Than Named Above:
Number of Pages: jit
IMPROVEMENT LOCATION CERTIFICATE
30 5-
600e.
REMNANT
BUILDING
26 47' CLEARANCE
Win
m
Y
uS
co
1005.0O' P L,
COUNTY ROAD
SHED
►U'X20')
lag
?1.
SHED
e•17 Wet�
ONE STORY
FRAME HOUSE
• sefig its
La
ro
BARN
{-38.01X26 5')
171.9.
85,+r s�
BIN
SHELTER
{4 D'X Z{1'}
N
• STORAGE
0#8'X28`)
pi' ROM
1005.00' Pt.
LEGAL DESCRIPTION:
J
0
0
Cn
4,0
Co
107 2001
SCALE: 1" = 100'
LOT A OF RECORDED EXEMPTION NO. 1473-07-1-RE1B41 RECORDED APRIL 23, 1996 AT RECEPTION NO. 2487144,
LOCATED IN THE WEST 112 OF THE NORTHEAST 114 OF THE 6TH P.M., WELD COUNTY COLORADO, COUNTY OF WELD,
STATE OF COLORADO.
I hereby certify that this Improvement Location Certificate was prepared for
FIRST AMERICAN TITLE that it is not a land survey plat or improvement
survey plat, and that it is not to be relied upon for establishment of fence, building, or other future
improvement lines. I further certify that fhe improvements on the above described parcel on this date
October 8,. 2020 , except utility connections, are entirely within the boundaries of the parcel,
except as shown, that there are no encroachments upon the described premises by improvements on
any adjoining premises, except as indicated, and that there is no apparent evidence or sign of any
easement crossing or burdening any part of said parcel, except as noted.
OWNER: CAMILA VANESA LOPEZ and YOEMNI ORTEGA MARRERO
ADDRESS: 18514 COUNTY ROAD 12
FORT LUPTON, COLORADO 80621
TITLE NO:
DATE: October 8, 2020
Laren:to,
2014 11:1lPM Chi/ton 6otei *217
is Tank Size: -5-41 gids' _flaws Paw*.
I bit SUSIE Yee No K if yes, tuactiodur Arts
013. ftscoratve water : Q— Poop Mtn Yes yes, fitnetioninic nouns beck Sotuck tam fi.dd? Its
If yes, ostimino to, Woos: a
la ratek over Witt Itinel Yet Not
5. lankak one)
ConcreteZ. Metal Cesspool or Boyne tks —
Pit � Other
Areti)r
B. Caw onado dead sad istspeced (if
9. Ames to cicsfrat lids wittikil locks of , ?
hit Notacia Owlet Ye:La.No
10. 2fi plastio mined S naiad ova tank tid (flood plain Syr Yee,_
'� 4
a� b
�d1Other conatitions med.mayaffect papa $
2
hetb tyt‘iii;
ems,
Inspector
�� �•! saai iaFirtr71: ill irk c al ffin ta •. a
lk
A-1 Septic Service
P.O. Box 1015 0 Brighton CO 80601
303-659-0610
STREET ADDAIES, _ / / l C /4•04
INSPECTOR NAME: ? c., ---ne
COLORADO PE #: NAWT rf NA79SS7WT
PUIPLNQ AND INSPECTION CONDITIONS
Were all compartments of multi -compartment tanks pumped?
Was all liquid and sludge removed leaving no more than 3 inches in tank?
Was the owner notified of any deficiencies noted during pumping?
Tank Type
Concrete Ci Plastic
ESTIMATED CAPACITY OF TANK(s)
Abc v
chambered system
U seepage pit
D Other
Tank Components
* Lid(s)
*Integrity
*Dosing siphon
*Internal Tees it baffles
;Effluent Filters / screens
Back flow after pumping
SITE. WEATHER AND OCCUPANCY
'sr -Erosion?
{Improper discharges?
Improper vegetative cover?
Subject to compaction?
Snow cover?
Property vacant?
❑ Fiberglass
f
0 Other
Li drip irrigation
„hifseepage trench
FAIL
FAIL
PASS FAIL
PASS
PASS FAIL
YES
gallons
. YES
,AYES
EYES
NO
LINO
LINO
U seepage bed
UETbed
ikti °'c rr
err . - `,4, Lay7,47-- Pp 'fiess "nay SP ,e 4er S, r';- oe
NA .._
c r i's DID"'A fret ' e 0"17— 4' s.
act' l oct&
CONDITIONS DURING INSPECTION
FAIL
FAIL
�l
403
NO
ABSORPTION f EVAPORATION SYSTEMS
Visible Components
''Vent / observation pipe
U Box / valve box
Surface Dampness?
Odors?
Liquid in ohs.. / vent pipe?
ELECTRIC LIFT I PUMP STATIONS
*Lid(s)
*Tank integrity
*Pump and controls
YES
YES
YES
PASS FAIL
PASS FAIL
igrP YES
YES
NONE Liquid depth is
Arid
PASS
PASS
PASS
FAIL
FAIL
FAIL
NO
:trig
p'fiarteviLC.
inches
NA1
NA.*
l hereby certify that I have inspected the above individual sewage disposal system in accordance with the County
Department of Health a n d Environment and that my comments end observations accurately reflect th.e physical and
operational status of the system and its components on the date of inspection.
yr
!1
Date
a
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