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Home My WebLink About20201858.tiff Scanning Cover Sheet for Septic Permits Permit # SP-0500261 Permit Type: Health/Residential/New Situs Street Address 14510 CR 6 Situs City, State, Zip Sec/Town/Range: 28-0IN-66W _ Application Status: Finaled Application Date: 05/01/2008 Parcel # (12 digits) 147128000050-R0341394 Owner Full Name: OMAN ROBERT D & Owner Address: 14510 CR 6 FORT LUPTON,CO 80621 Owner Phone #: Contact Name: OMAN ROBERT Contact Address: PO BOX 280 FORT LUPTON,CO,80621 Contact Phone# 303-637-9447 Information above has been Verified in Accela by employee noted below X May 01, 2008 Processed by: Date Report ID: EHS00024v003 Page 1 of 1 Print Date -Time: 5/1/2008 11:22:48AM WELD COUNTY DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT 1555 NORTH 17TH AVENUE GREELEY, CO 80631 ' r� • PHONE(970) 304-6415 FAX (970) 304-6411 Fina led Permit#: SP-0500261 Sec/Twn/Rng: 28 01 66 Status: APPLIED Owner: OMAN ROBERT Applied: 07/15/2005 Applicant: OMAN ROBERT Issued: ri- -O5 Permit Type: RNEW C=Commercial,R=Residential+NEW,REPair,VauLT . Finaled; ri-a9--O5- Parcel #: 1471-28-0-00-050 Location: 14510 WCR 6 Legal Description: 15975 PT S2NW4 28 1 66 BEG S0D03'E 1319. 33'N89D51'E 685.57' Installer: OwiA-ft-k- . . . ___ Description: BARN Commercial: N Residential:Y Acres: 57.4 #of Persons: 0 Basement Plumbing: N #of Bedrooms: 0 Bathrooms-Full: 0 3/4: 0 1/2: 1 Water Public: N Water Source: Water Private: N Cistern: N Well: Y Well Permit#: 184986 Percolation Rate: 39.8 Limiting Zone: 7 ft 0 in Description: groundwater %Ground Slope: 1 Dir: N Soil Suitable: (Y/N) Y Engineer Design Required: (Y/N) In 100 Year Flood Plain: (Y/N) Minimum Installation Chambers* Septic Tank: 1000 gallons Absorption Trench: 284 square feet or Absorption Bed: 0 square feet Actual Installation qcp Septic Tank: gallons Absorption Trench: square feet Absorption Bed: , ' `..,: square feet ..---- Design Type: CA Chamber Model _ NOTICE The issuance of this permit does not imply compliance with other state,county or local regulatory or building requirements,nor shall it act to certify that the subject system will operate in compliance with applicable state,county and local regulations adopted persuant to Article 10,Title 25,CRS as amended,except for the purpose of establishing final approval of installed system for issuance of a local occupancy permit persuant to CRS 1973 25-10-111 (2). This permit is non transferable and non refundable. The Weld County Department of Public Health and Environment reserves the tight to impose additional terms and conditions required to meet our regulations on a continuing basis. Final permit approval was contingent upon the final inspection of the completed system by the cid CourtDepartment of Public Health and Environment. • x Olin 11,1 Environmental Health Specialist Date Form:S_FINAL 4 A FOR OFFICE USE, ONLY ISDS APPLICATION FLOW SHEET Owner: Permit #: ' -O O Z L Location: 1`7 ti D w o Legal Description: -e{ - Date By Comments _ Parcel Number Received 45145 Information Form Complete Authorization Form Received Map Drawing Received Flood Plain? Yes/No Site Inspection Date Engineer Design? Yes/No Date Engineer Design Received Customer Notified? Yes/No Date Staff Approval Sent Date Staff Approval Rec'd Perc Data Entered in Computer Date of BOH Approval Eng Approval Letter Sent (Letter, Permit, BOH Review) Date of Final Inspection Eng Final Inspection Letter Recd Variances Needed?Yes/No Sent Variance Staff Approval Rec'd Variance Staff Approval Variance BOH Approval Variance BOH Approval Sent (Variance,BOH Review) • Additional Comments:_ M Ian rprewsepikrhoweroaeG SOb.wpd WELD COUNTY DEPARTMENT OF PUBLIC HEALTH AND ENVIRO t►, • 1555 NORTH 17TH AVENUE GREELEY, COLORADO 80631 tep PHONE (970) 304-6415 FAX (970) 304-6411 - 1 Permit#: SP-0500261 Sec/Twn/Rng: 28 01 66 PERMIT Owner: OMAN ROBERT Applied:07/15/2005 Applicant: OMAN ROBERT Permit Type: RNEW C=Commercial,R@Residential + NEW,REPair,VauLT Parcel#: 1471-28-0-00-050 Location: 14510 WCR 6 Legal Desc: 15975 PT S2NW4 28 1 66 BEG S0D03'E 1319. 33'N89D51'E 685.57' Description: BARN Commercial: N Residential:Y Acres: 57.4 # of Persons: 0 Basement Plumbing: N #of Bedrooms: 0 Bathrooms -Full: 0 3/4: 0 1/2: 1 Water Public: N Water Source: Water Private: N Cistern: N Well: Y Well Permit Number: 184986 Percolation Rate '30[.y Limiting Zone`" ft in Description 41191tncliikgsk %Ground Slope } Direction 1� Soil Suitable /N) kres Engineer Design Required(Y/N) \&1 In 100 Year Flood Plain (Y/N) 1,1a From the application information supplied and the on-site soli percolation data the following minimum installation specifications are required: Septic Tank OW gallons, Absorption Trench 02•154 sq ft or Absorption Bed — sq ft Chambers: Infiltrator or Rancor Standard or Hi-Capacity, EQ36 or BioDiffuser Trench 0 Bed Infiltrator Quick4 Trench _ Bed Hancor Narrow(15in)Envirochamber Trench Bed In addition, this permit is subject to the following additional terms and conditions: -1AblUzohnt. &Ad 1405-. q14-4eArt 609-4-421/it_ • NOTICE This permit is granted temporarily to allow construction to commence. This permit may be revoked or suspended by the Weld County Department of Public Health and Environment for reasons set forth in the Weld County Individual Sewage Disposal System Regulations including failure to meet any term or condition imposed thereon during temporary or final approval. The issuance of this permit does not constitute assumption by the department or its employees of liability for the failure or inadequacy of the sewage disposal system. This permit is non transferable and non refundable. Before issuing final approval of this permit the Weld County Department of Public Health and Environment reserves the right to impose additional terms and conditions required to meet our regulations on a continuing basis. Final permit approval is cant ent upon final ' jeciion of the completed system by the Weld County Department of Public Health and Environment. � f x Form:SJPERMITN Environmental Health Specialist Date 'YA,I14t'uL k-(4 OcAta cpes_) 3xCapo_xw^a mow. ` v ires\tsA,si AAA-- '¢sr-'4- 4Uu mac, otiL _At9, 6,kK , NO1' 1 � <\6A\ $-P ya AkiA r'14 j$"11' t 1)ekig 4?1 ke\i bUir rc��5' WELD COUNTY DEPARTMENT OF PUBLIC HEALTH&ENVIRONMENT i 555 NORTH 17TH AVENUE, GREELEY,CO 80631 PHONE: (970)304-6415 FAX: (970)304-6411 WEBSITE: WWW.CO.WELD.CO.US APPLICATION /RECEIPT Initials: SC Permit Number: SP-0500261 Receipt Number: HAP-05266 07-15-2005 Amount: $400.00 Payment Method: Check Notation: 1297 Owner Name: OMAN ROBERT Applicant Name: OMAN ROBERT Parcel Number: 147128000050 Location: 14510 WCR 6 Account Code Description Amount 2560-41400-4221-4203 New Septic Permit $400.00 2560-41400-4221-4203 Repair Septic Permit $0.00 2560-41400-4221-4203 Vault Permit $0.00 2560-41400-4221-4203 Variance Request $0.00 Description: BARN Commercial: (Y/N) N Residential: (Y/N) Y Acres: 57.4 Number of Persons: 0 Basement Plumbing: (Y/N) N Number of Bedrooms: 0 Bathrooms: Full - 0 3/4: 0 1/2: 1 Water Public: (Y/N) N Water Supply: Water Private: (Y/N) N Cistern: (YIN)N Well: (Y/N) Y Well Permit Number: 184986 TERMS AND CONDITIONS A permit fee,as set by separate ordinance of the Board of Weld County Commissioners,shall be required of applicants for new individual sewage disposal systems(ISDS),payable at time of application.Permit fees are rrorirrefi ndable;permit applications are no Wrapsforeblo_If both a building permit and an ISDS are issued for the same property and construction is not commenced prior to the expiration date of the building permit, the ISDS permit shall expire at the same time as the building permit. If an ISDS permit is issued for a property that does not require a building permit,the ISDS permit shall expire one year after its issuance if construction on the septic system has not commenced, Any change in plans or specifications after the permit has been issued invalidates the permit unless approval is secured from the Health Officer or hister designated agent. Expired permits can be renewed by payment of the permit fee only if: A.There has been no change in the plans and specifications of the proposed system as set out in the original application or such change is reviewed and approved by a Division Representative, B.The surrounding land,its use or zoning has not changed so-as-to cause the original application not to be acceptable under these regulations. NOTICE The completeness of this application is conditional upon further mandatory and additional tests and reports as may be required by the Weld County Department of Public Health and Environment(WCDPHE).The issuance of the permit is subject to such terms and conditions as deemed necessary to insure compliance with rules and regulations adopted under article 10 title 25,CRS as amended.The applicant certifies that the proposed system will not be located within 400 feet of a community sewage system.The undersigned certifies that all statements made,information and reports submitted herewith are,or will be,represented to be true and correct to the best of his/her knowledge and are designed to be relied on by the WCDPHE for evaluation for purposes of issuing the permit applied for herein.Applicant further understands that falsification or misrepresentation may r in the denial of the • . i tion or revocation of y permi zed,and in legal action of perjury as provided by law. 7 /. ,O1----- wner/Applicant Date Form:RT,HAPP • t . SEPTIC INFORMATION FORM - — To obtain an I.S.D.S. permit, one must file an"application for Individual Sewage Disposal System"at the Weld County Environmental Health Services office and C pay the application fee. A"repair" fee shall be charged for the expansion, replacement, or repair of an existing system. The following information must be COLORADO provided on the septic information form. PARCEL NO.: (12 DIGIT NUMBER) CAN BE OBTAINED FROM THE ASSESSOR'S OFFICE AT(970)353-3845 EXT 3650 PROPERTY OWNER: 920c3q,z---7- MAILING ADDRESS: I e - CITY ST CO ZIP c4 Z1 HOME PHONE: (037 411V2 WORK PHONE (303) Ga-0 6434 FAX ( 5 63) APPLICANT NAME: MAILING ADDRESS: PD 60 cPtirC) MVP-419k" ST [ ZIP Po&2} HOME PHONE: 90 6'37 q'V97 WORK PHONE (303) Fri FAX po3 ) 2s-7 41 3e r ail, LEGAL DESCRIPTION PT 54, PT 4/W/4 SEC o2. TWN / /l/ RNG4e1 A/ ACRES 7 II SUBDIVISION j) /4 7 ► r30 • 2- LOT '7, BLOCK FILING DESCRIPTION OF BUILDING (EX:HOUSE,MOBILE HOME,MODULAR,SHOP,OFFICE) f,) SITE ADDRESS ] -F C 1O WC-ft 1.7 _ - DIRECTIONS TO SITE 431--- 5 NEW PERMIT ≥ REPAIR PERMIT VAULT PERMIT $ 400 $ 400 $ 150 IF OBTAINING A REPAIR PERMIT, PLEASE LIST PREVIOUS OWNERS OF THE PROPERTY: FLOOD PLAIN YES / O CENSUS TRACT RESIDENTIAL of{E /NO COMMERICAL '•l(�- ' NUMBER OF PERSONS fl'* BASEMENT PLUMBING 4Z /NO NUMBER OF BEDROOMS 40-- BATHROOMS: FULL 3/4 1/2 WATER SUPPLY: PUBLIC NAME fi 1 PRIVATE /NO CISTERN YES /r WELL / NO WELL PERMIT # ld cier,� PERC HOLES MARKED FOR INSPECTION BY SPECIALIST YES/NO Vier! 7 J r • -- • - r+� $r tit. - ..- r r"'•j /} lJ .{ Clr1•_en3 L` • •S r Y1�•t—+'. r;� !'•-•1 r_•rll Ysu.! _ l...,..t+ (/� '74•••.. _1JN1',. �•.L...f-..�.......... .. -. r.,— IJq oil aY.C,�t'. { Y35 (Ot CREYE I tHi I -- . • .,_..-...,..... .-. - •- '--- 8- h3LS i�I Sri}111:' . . G: .:;,rri. Ail t,rtivtnis =rva ;•as D•I ; AA CL:Fr. ^^i IrCvO-:i ,JjM1'f -- !'S ', + Ll;AA1,,i 'C:AL MINLyr•FS -IIGV:F^ y,ll^tDING TIME J 4iwg....t:i�:r: 1'T[Ll.7 SS'-.I.t._]bJ1i DF1�=.•RJ!: .A:a-PI1, a17,. . 1.!-!, ••••D•7-1-: .. I •.c.IMf rl'.rru•1111'±;r+ r5}e °rffsrlD 51rl w .1Y. , .,,•11w lt r' .rr' . .) A +.:nPu +.;+o ,.C, .+x :we 0,...1......7-rvc.•a;r+sc a• p_, tslt•;sr } yi •}rt 'M4' L'f1.�•F°' a0D°455 %. .1t • . Pik ai.•;,7 Crsi e4! .alueJAI Yte•Ci•If LLE dJTT .S'. - -1r .•:,.-...J _ - ar n . , _.. r , 'R ..- _ -- a l..- ci_'F�:"e'1.7 ?: OOa., .,s•F•@_A:C.,:3" ., .• (1)Pk,...e.OW "VIP:1.32= ticp T--.)ctik, h l Cinch Construction L.L.C. JUL Invoice 1 • 7451 Schumaker Rd f� 5.2o 3 - Date � Invoice# 303-644-4077 Bennett, CO 80102 '�ri((fkfive 12/12/2002 97 Bill To Ship To Select Material 14510 WCR 6 P.O.box 280 Fort Lupton;Co 80621 Terms Project - Due on completion . . .. .....-. ......�--,I_... - ___. ,—..-_ Item Quantity i Description --- -— Rate Amount p _ Backhoe 18 I Trenching 18 hr 60.00 1,080 00 Material 600 SDR 35 0.82 492,00 Material 12 90 de 2.70 32.40 I Material Tan- 660.00 660.00 Material pipe 115.00 115.00 Material pipe 75.00 75.00 Backhoe 20.33 backhoe 60.00 1,219.80 Labor 16.66 Labor 15.00 249.90 Material pipe And fittings 50.00 50.00 i i • ! I I I I I iI God Bless j I Total 53,974.I0 vv a a T Fa ri L.a WELD COUNTY DEPARTMENT OF PUBLIC SE# rO jor) I Li - t HEALTH AND ENVIRONMENT ORG PERMIT*1., 1555 N. 1T`"AVENUE REPAIR# GREELEY,COLORADO 80631 _ LOAN# II li C PHONE; X970)3846415 1SOS#T FAX: 9711 304-6411 COLORADO . STATEMENT OF EXISTING FOR SEPTIC SYSTEM (PLEASE FILL OUT IN BLACK INK ONLY) , PARCEL# t ' I2-r©ears 6V PROPERTY OWNER _ f-__ -/ J Y--_-- PHONE NO. ( ) (4'3 .7 951 c'7 MAILING ADDRESS /0 IAJC.i2 /gr r L` 11P7TJri/ t tom, "L r City State Zip DESCRIPTION OF BUILDS 1G(ex. house,mobile/modular home,shop,office) 4.2______________ SITE/LOCATION ADDRESS 4(14,570 J G 4,-'O1°7-41.4 �' a../ {{ �f�/� City State Zip LEGAL DESCRLPTION PT 1/ PT_ r5l SECTION '..S' TOWNSID.P j RANGE rte`/ 6,6 /4,4 SUBDIVISION / &C 1 P /9 7/7 -L P_ 1LOT .. BLOCK FILING et, 6v7h i CENCUS TRACT LOT SIZE/ACRES 71 4/ COMMERCIAL /NO RESIDEN'T'IAL YES/N g& NUMBER OF PERSONS_ Z, BASEMENT PLUMBING 'M6/NO BEDROOMS 12 BATHROOMS FULL _ 3/4 112 )C WATER SUPPLY PUBLIC VILPS!Nfig•• UTILITY NAMT PRIVATE - CISTERN loglit/Mto WELL YES/.65 WELL PERMIT /116 (SYSTEM SIZE: Septic tank material is constructed of OM IT and has [.510 gallons c:� acity. FIELD: Trench '7 square feet or Bed square feet YEAR INSTALLED A,aa2-. r 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 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 imowledgedpindwfailing to function properly. • • I further understand that any falsification or misrepresentation may result in rev rtnit granted based upon this information hereby submitted and i action for p u provi e r�,4`/1/44i4/0 3 . e.W-4. -• DATE OWN`E Subs an sw to bef'o me this �— day of ............ '� •'••• by c My 4110001m bons are Witness my hand and official seal. 13y mmissiou expires:,-5. xpires:, -`,..30 -1-.)5' - /I I DATE OTARY PUBLIC STATEMENT OF EXISTING REVIEWED BY ENVIRONMENTAL HEALTH SPECIALIST *iv r 3r 75 . f - ii•iii 1 , 1 + P . 1 1f it ,- . __17)...... i .-44.: 4 1 • ` I 1(iiiiiitilbb da IIP!.,.i • ) .r_ I.•,... -.r • 4-- ...R.I., ., , 1 ,C-. y . }1l. . , 1 ‘.1..) ? t '�i 0{6' qtr 4 ' ' L -- ti Ai i S %t 'S; 4� -.' kl;.° IN '.Z. ..-.. 4 . .... „, .t ' • 1 i\-j...'1 ,' f) . . ... ,,, .. .-4.•:. ''''..4tr • 2" )1'''' • • ' :1`,••• ,,..e.. --iiir • . . r • Aillikit* „iir.• 4.Y 4• • / _. n '" i - •• r,fy'- 14.. • } , Y% It -1. N. ft i. +r .4 - ,.. ,.. ,^yy .A1 r', ` ~ - .:I.. .1‘,4"- — I V r• L•. ti yd lL41!' S▪ ' s Ff,T -: r .•,..y. '`r•� ' '.4• ...16;.:•;,' "i�++. 4ri k•.-' - . r r . . ▪ .r�.. Let. v Y ,► {" - •` .."\-7 \- .�� . i - Irj ..-41... ...';,.' ..,n <17,--‘ 46 A. -w 4, 7 0. -r *_, • S• p-' , • .4 •y f L' f .P;rr_�i ri d f •A, ff ..*:,.7."°%.',.-'-__4•'.''Vlibit.4"..ie '...".10" 4:' 3 • ••••' . ' `#•••tifie ...---1 r r r ildlier f V�•r • ' } r Weld County Health Department 7/15/2005 Percolation Test and Soils Data VI '‘ . �1., ,; High Plains Engineering - . "` ,r,, 735 Denver Avenue • Fort Lupton CO 8082 1 P a i Phone 303-857-9280 • Fax 3O3-857-9238 4ri d . FILE MO;-0.5-4686 - I Property Address 14510 WCR 6, WELD COUNTY,CO Legal Description Property Owner Info Name SELECT MATERIALS Street P.O. BOX 280 City;State,Zip FORT LUPTON, CO 80621 Phone 303-857-4688 L �;'Saturation.and Swelling. r • I - Graun Smeared Surfaces !Encountered at [ 7lfeet ....) Removed: YES Sand or Gravel Added: NO Estimated depth to maximum seasonal water table if not Date and Time Presoak 7/14/2005 date encountered in 'rofile: Water Added: •:I I time Amount of Presoak Is area believed to be subject to Water Added: 15 gallons seasonal fluctuations which could • Date and Time result in a seasonal water table,within Percolation Test 7/15/2005 date 8'of surface? Started: 9:00 time .,Slope•Determinatibn in'Absorption=Area - Did Water Remain in Hole After the Overnight Swelling 1 % Period? - to the NORTH direction Hole-1 NO • Hole 2 NO .:. --- Bedrock=:.-.. . J Hole 3 NO Encountered @ !GREATER THAN 8 'feet Hole 4 NO Hole 5 NO Estimated depth if not encountered in Hole 6 NO I profile: I_rcoIatibn Rate Percolation Measurement Deep(In) Rate(mln/in) Hole 1 36 33.33 Type of Bedrock:1 Hole 2 36 55.56 Hole 3 36 41.67 Hole 4 36 33.33 Is bedrock fractured_or_weathered? Hole 5. 36' 33.33 Hole 6. 36 -67 Is bedrock believed to be permeable Average _ __ 3'.: (pert rate a 60 minim)? _ 4.• Weld County Health Department 7/15/2005 Percolation Test and Soils Data [Profile Hole information (cont,) Note: Soils must be classified using unified s stem ASTM D2487 'Profile Hole Log --- - - 0 A 1 SANDY CLAY(SC) A ar c -—_3 CLAY WITH LOW PLASTICITY(CL) 4 0 —i ' SANDY SILT(SM) �..r A -— 6 CLAY WITH LOW PLASTICITY(CL) 7 „ LIMITING LAYER WATER TABLE a SANDY SILT (SM) 8 • 9 10 I certify that the above information is correct and complete to the best of my knowledge and that all tests were performed in the accordance with the provisions of Weld County Health Department individual sewage disposal regulations by myself or under my supervision. High Plains Engineering Signature r' :'�- ell C2 735 Denver Avenue Ft. Lupton, CO 80621 l�+r%•e; ft/3149-.7,_% , 303-857-9280 Date ytil r Al =4 \yt�R •• SITE MAP I45IOWCR6 WELD COUNTY, CO LD O • to w U • • • • • •X - - 15O 25 j x — x —�c EXISTING BARN LEGEND All locations shown above are based on specific information furnished by others or • Percolation holes estimates made in the field by High Plains Engineering personnel. The locations, distances, directions, etc. are not the result of a property survey but are X Percolation Profile Hole approximations and are not warranted to be exact. It i5 the owneribuilder's d Sot Profile hole responsibility to define property - boundaries and ensure all onsite improvements are located within the platted site and out of inappropriate easements. All Fence distances are to be verfied prior to excavation. Scanning Cover Sheet for Septic Permits Permit # G19950259 Permit Type: Health/EMS History/EHS Conversion History Situs Street Address 14510 CR 6 Situs City, State, Zip Sec/Town/Range: 28-01 N-66W Application Status: Finaled Application Date: 03/11/1996 Parcel # (12 digits) 147128000050-R0341394 Owner Full Name: WAGNER JOHN Owner Address: 9885 WEST WESLEY AVENUE DENVER,CO 80227 Owner Phone #: • 303 9800495 Contact Name: Contact Address: Contact Phone# Information above has been Verified in Accela by employee noted below May 01, 2008 Processed by: Date Report ID: EHS00024v003 Page 1 of 1 Print Date -Time: 5/1/2008 11:32:19AM 1•iS1::':l.{)lal: INDIVIDUAL:1:V:I:S)I.IFwL SEWAGE (DISPOSAL ::3YS:31"E:•:l''I PERMIT l'1:E: T' NO. (:J-•••9':',t):<:':�9 WI:I,..C) COUNTY r HEALTH 1 1••! DEPARTMENT k T NEW PERMIT T• l:::hfVIF:[f7NIYIE::NT AL.. HEALTH#.-1 SERVICES 1517 :l .. u I..I AVENUE COURT , (:'JF{f;::l:;:I..I:::Y„ CO 806;;T:l. 353-0635 EXT .2225 OWNER WAGNER, JOHN ADDRESS 9885 WEST WESLEY AVENUE I.::I..! (::i0 3) ','t:3{1•'•'<)r'T'K LAKEWOOD CO 8{)221 ADDRESS OF PI:4(,1F'(:JS:3(:::T) SYSTEM 14510 W(:;F: 6 FT L..(.I 'T'(:iN CO B0621 LEGAL T)l:::S:}(:ik::::E:l"''1":11)1'! (:11:- S:3:(:'T•I:::,, ::3I:::(:: ::14.d T•Wl::' :I kl'lu 66 SUBDIVISION;; I..(::'T 0 T':{L•.(:J(::CI< O FILING S) USE r'YI::'E::::; 1:41:':S:3:1:T)IiI.E'•I'T':F.Al.., HOUSE SERVICES PERSONS 3 BATHROOMS 2.00 LOT SIZE 57.00 BEDROOMS 'b BASEMENT T PLUMING iG YES WATER E:.l•4 SUPPLY l••'L•JI::.E...1.. G4f:'l:l...:i:CAT':I.c:i i l::'l:::I.i: $265.00 RE::(:. '3) BY LISA f:;1 1J SIGNED BY 0(:11••Ihl D. WAGNER DATE::: 07/A2/95 DATE:: 07/:1.2/95 PERCOLATION RATE is.'' MIN I::'i:iR INCH I LIMITING 1(:JI'IEi: 8 FEET ::3(:1:1:1... 'r'Yl::'1::: SUITABLE PERCENT GROUND SLOPE 0)-',, DIRECTION ]:ON FcI:::(:iLi:I:I:I:::S:3 ENGINEER T)1:::S:31:(::;I I NO IN :1.11(1 YEAR 1:1...f1(:)T:) 1::I..-r7:LI I ZONE ND FROM I 'rIiI:i: APPLICATION`(::'I...:l:( 5"T:I ON INFORMATION:I:ON SUFI::I...:1:ED AND THE ON—SITE S(:J:I:L.. PERCOLATION DA'Tr: THE I::CII••,I..... :r c N:i:w:1:MLIII INSTALLATION SPECIFICATIONS ARE l: E::l(Ja:F::IF.:T:ti;; SEPTIC TANK 1250 GALLONS, ABSORPTION TRENCH 732 SO. F:T. OR r"BS:S[iRPI :!:(::cl•I i:i :T) :1.000 t:}Ci„ I::--T.. :1:1••1 ADDITION, • ••13:S:3 F'l:::F::l'-l:1:'T IS S:}LJJ:•?j1:::(::'T' -1Ci TI-•11::: FOLLOWING ADDITIONAL TERMS AND CONDITIONS THIS IS:3 PERMIT IS GRANTED TEMPORARILY i,..'Y' 'r(:1 ALLOW CONSTRUCTION TO COMMENCE. THIS PERMIT :F':EYi:1:'T' MAY BE REVOKED OR SUSPENDED BY THE WELD (:::(:1(.INT`s' HEALTH DEPARTMENT 1 FOR REASONS SET FORTH IN THE WE:I...I) COUNTY :1:1.1():I:l1:l:T)(.IA:`IE... SEWAGE DISPOSAL SYSTEM REGULATIONS.1:(:Jii :l:NIC::1...(.1S):I:NG FAILURE TO MEET ANY TERM OR CONDITION :1:lY11::'(:1S:3E:::D THEREON I:L.JI: :CNO TEMPORARY OF:: F:':I:HAl... APPROVAL. 'rl'-ic: ISSUANCE OF THIS F:ERNI:1:1 DOES NOT CONSTITUTE ASSUMPTION BY a -il::: DEPARTMENT c:II: :1:T'.:3 I:-1Y!!::'k...(:JYI:::I:::f:3 c 1:: 1...:1:"'11ir:I:L.,:I:T'Y I:c:LT;; THE FAILURE OR :I:i•il•11)E;:f:i(.Ir"r(:;`r' (:1F.. THE S:31:::Wr'1i:31i:: X)II:S'IP::'C1S:3r^d... SYSTEM . �1_� PAM SMITH 07/18/95 r`4 • 0- E-?S ENVIRONMENTAL SPECIALIST I)A'r I:,: r'I"I:1:ET PERMIT T 1:f:1 1-IC1.T. TRANSFERABLE r-^IRIS) `::31••!8!...1... !:}I :(:.(:11'•11::: '',+(:J:I:T) :1:1:F SYSTEM CONSTRUCTION HAS HOT COMMENCED WITHIN 1:JNl::: YEAR (:JE::' ITS :I:S:3S:31.Ir'`11••I(:::1:::.. TiI:::F:'fII:I:: :l:i:;;:3(.1:I:NC) I':':I:hl{`Ik.-- APPROVAL OF THIS F:'f:::l'R;IYI:I:l" 'r'!-•IIL: 1WE::L..T) c:CiIJI''I'rY HEALTH DEPARTMENT RESERVES rl'•IET F:;:I:(}iI..... .1..C) IMPOSE ADDI- TIONAL T'4:::RMS AND CONDITIONS i-IT):l:T'Ic)1 IS F:i :(;lLI:I:RI:TI) TO IYlI:':E::'T' C](.IR REGULATIONS IDI'd A CONTINUING BA- SIS. FINAL PERMIT APPROVAL IS CONTINGENT I(:a1:::N'I UPON T'F!! : FINAL INSPECTION OF Till::: COM- PLETED SYSTEM BY THE WELD COUNTY HEALTH 1)EPARTMEN i .. {:, {,... V :11 MST ::. . _...._.... apt er ... Fa:I,lral... :CL• ..aI::'F•::(::r : KATE: ...//"7.. .., ,I l NG,:EHEE 1:::1:: APPROVAL Y tiv ..�.C4 .........7.... ENVIRONMENTAL... TYPE [:,1:� S:;`r`;:3'T'E::1 I .l:I'�E;:�T'r�51...l...E::1:. `r • � 7r�w[+/C S:3PI;:'l.: 1••u_.• 1 T1IIT: ISSUANCE OF T'I"I:l:S13 1:-I:::IIYM:I: 1 :(.c:tES l-I(:J'r' IMPLY ('r(:JIYI1I...:I:1'lN(: I::: W:1:T'I--I OTHER STATE. (..(:LINTY OR L.,l:1(:;fi71... REGULATORY OR BUILDING I I (:i1I:Ei: I IYlE1~ITS,, NOR SHALL IT ACT TO CERTIFY THAT THE S:3(.JB Tli::(:','T SYSTEM T ELIYI WILL OPERATE T'I::; IN I COMPLIANCE lf::I iii rT I•I APPLICABLE STATE (:::f:1(.il•11'i AHD l._O(:'.A1... REGULATIONS ADOPTED F:'IRS:3(.Irrlhl'1 TO ARTICLE :1.0 TITLE 25„ s:'1:4t:3 :L"i''%';:3., AS AMENDED, EXCEPT FOR TIlE: PURPOSE OF ESTABLISHING FINAL t•`•s1::'!"'1::;O'VVAI.., O1::- AN INSTALLED SYSTEM FOR ISSUANCE: OF A I...Or(:AL.. OCCUPANCY PERMIT PURSUANT TO CRS 1973 25-10-111 C2.1 ,. r fl ria r KJAs PI T.r' 'I\l..(.„ ( r71; ;f....I1 :1..11 1'1 1-1q NAY . d . I\ ,..... .,_____— - -_______,\ P:' ,IL 6O i rift% _ „, U9 '/ vi 0' 1 9.4' -----_____:--------------. \ troi,t 6 a 1 zi , -tP1.O6P INDIVIDUAL. SEWAGE DISPOSAL SYSTEM PERMIT NO. S-950259 WELD COUNTY HEALTH DEPARTMENT NEW r'ER!'!I- . ` ENVIRONMENTAL HEALTH SERVICES 1517 UUTH AVENUE COURT. GR:EELEY, CO 00631 :153-0635 EXT,2225 OWNER WAsNER, JOHN ADDRESS 9885 WEST WESLEY AVENUE PH i=03) 980-049'7. LAKEWOOD CO 90227 ADDRESS OF PROPOSED SYSTEM 14510 NCR 6 FT LUFTON CO B06r2_1 LEGAL_ DESCRIPTION OF SITE: SEC 28 TWF 1 RNG 66 RUBDIVIBI❑N: LOT 0 BLOCK 0 FILING 0 USE TYPE: RESIDENTIAL HOUSE SERVICES: PERSONS „ BATHROOMS,THROOMS 2.00 LOT SIZE 57.00 ACRES BEDROOMS OBASEMENT PLUMBING YES WATER SUPPLY F'WELL. APPLICATION FEE s 2Z5.0o RECD SY LISA RAU SIGNED BY JOHN D. WAGNER DATE (]7/12/95 DATE E 07/12/95 PERLOLATION F4TE 6O_ MIN PER INCH LIMITING ZONE A FEET SO;L ..,..,,F_ L 4XutiNePERCFNI GROUND :DL-OF.E Y... DIRECTION RECI..IIRES ENGI:NE.E DE 011 N ',D IN IO l4L.U YF F-LUuD F'LAiiN ,TON"E FROM THE APPLICATION. INFORMATION SUPPLIED AND THE ON-SITE SOIL PERCOLATION! DATA THE FOLLOWING MINIMUM INS�.�TyA�L-LATIUN SPEC.'Cf' I'LATIONS ARE REQUIRED::` E-FTTC TANKDIVP_- GALLONS, ABSORPTION TRENCH •-3 SO. FT. CR ABSC P'TIUI\! BED 1 _ SO. FT. IN ADDITI❑N, THIS PERMIT IS SUBJECT TO THE FOLLOWING ADDITIONAL, TERMS AND CDND,1TICINSe THIS PERMIT IS GRANTED TEMPORAR'f'L..Y TO ALLOW CONSTRUCTION TO COMMENCE. THIE PERMIT MAY BE REVOKED OR SUSPENDED BY THE WELD COUNTY !HEALTH DEPARTMENT FOR REASONS SET FORTH IN THE WELD COUNTY INDIVIDUAL SEWAGE DISPOSAL-, SYSTEM REGULATIONS INCLUDING FAILURE TO MEET ANY TERM OR CONDITION IMPOSED THEREON DURING TEMPORARY OR FINAL APPROVAL. THE ISSUANCE OF THIS PERMIT DOES NOT CONSTITUTE ASSUMPTION BY THE DEPARTMENT OR ITS EMPLOYEES OF LIABILITY FOR THE FAILURE OR INADEQUACY . OF THE SEWAGE DISPOSAL SYSTEM. o4,-;47,0 SI 'EC'IAI__iST DA.r E THIS PERMIT IS NOT TRANSFERABLE AND SHALL BECOME VOID IF SYSTEM CONSTRUCTION HAS NOT COMMENCED WITHIN ONE YEAR OF ITS ISSUANCE. BEFORE ISSUING FINAL APPROVAL OF THIS PERMIT THE WELD COUNTY HEALTH DEPARTMENT RESERVES THE RIGHT TO IMPOSE ADDI- TIONAL TERMS AND CONDITIONS REQUIRED TO MEET OUR REGULATIONS ON A CONTINUING BA- SIS. FINAL PERMIT APPROVAL IS CONTINGENT UPON THE FINAL INSPECTION OF THE COM- PLETED SYSTEM BY THE WELD COUNTY HEALTH DEPARTMENT. ^ri l.i'.r•.. l ,riT . -r... i .-1,,-i 1r-, Y. r-. . v... . ...5.�'Ji + 'Ir L. VELD COUNTY HEALTH DEPARTMENT ENVIRONMENTAL PROTECTION SERVICES SITE £VALUATION OWNER: :e . APPLICATION NO. : tic �7 SITE:111.111e_____C� PT s 2 Ti RLAO PATE: rl11cP5 SUBDIVISION: --- LT BLK FLG PERCOLATION TEST DATA: Start Time: Hole Hole H2O (D 10 10 I0 min. No. Depth Remain min, min. min. min. - min. min. min. min. min. I ct • cam qK Db (gob 1 do y5 55 - - ,I r le030 cD U 1 4L (0,4 S.6 .t .0 ,5 ( ' 4-3 S 4 t 0 - Oar) C , cwo 5 3,0 (i 45 1) ' 1.15 _ r0 •_c,to n ‹ ,, „i„ ,,, .O ,„,, („,, . 6 All measurements in .mm unless otherwise indicated. 141A 11, * - Add H2O Total Environmental Specialist Average Rate Iji`(i tocelo PLOT PLAN 4 SOIL PROFILE +I-----7E7z 'f (bc�-li L 6ro � a 4 AP'P'LICATION FOR INDIVIDUAL SEWAGE .DISPOSAL SYS i Ei'1 NO. E.-3502 :c; WELD COUNTY HEALTH DEPARTMENT NEW APPLICATI`;si1 ENVIRONMENTAL HEALTH SERVICES 1517 16TH AV�I i Ei�g( 1?RT¢xi:r F.-i;.,1 Y. CO €30631 • LJNER WAGNER. JOHN ADDRESS 9885 WEST WESLEY AVENUE PH! (30.1) 9B u-0495 95 LA<:EWOOD CO 602' 7 ADDRESS OF PROPOSED SYSTEM 14510 WCR 6 FT LUF'TON CD G0621 _ sn_ DESCRIPTION OF SITE: SEC 28 TWF' 1. RNS 66 SUBDIVISION: LOT C) BLOCK 0 FILING 0 USE TYPEn RESIDENTIAL HOUSE SERVICES: PERSONS 7 BATHROOMS 2.00 LOT SIZE 57.00 ACRES BEDROOMS 4 BASEMENT PLUMBING YES WATER SUPPLY F'WELL APPLICANT ACKNOWLEDGES THAT THE COMPLETENESS OF THIS APPLICATION IS CUNdI fIONAL LJF'ON FURTHER MANDATORY AND AD.DITIONAUU TESTS AND REPORTS AS MAY BE REQUIRED E+•'• THE WELD COUNTY HEALTH DEPARTMENT TO BE MADE AND FURNISHED BY THE APPLICANT OR THE WELD 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 TO INSURE COMPLIANCE WITH RULES AND REGULATIONS ADOPTED UNDER ARTICLE 1(:)0 -TITLE 25. CRS 1971% AS AMENDED. THE APPLICANT CERTIFIES THAT THE PROPOSED SYSTEM WILL NOT DE LOCP,TED WITHIN 400 FEET OF A. COMMLIN11 Y SEWAGE SYSTEM. THE UNDERSIGNED HEREBY CERTIFIES THAT ALL STATEMENTS MADE. INFORMATION AND REPORTS SUBMITTED HEREWITH AND REQUIRED TO BE SUBMITTED Dv THE AF''-='LICANT ARE, OR WILL 3E, REPRESENTED TO DE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF, AND ARE DESIGNED TO BE RELIED ON BY THE WELD COUNTY HEALTH DEPARTMENT IN EVALUATING THE SAME FOR PURPOSES OF ISSUING THE PERMIT' APPLIED '-OR HEREIN. I FURTHER LINDE.i --' STAND THAT ANY FALSIFICATION OR MISREPRESENTATION MAY RESULT IN THE DENTAL OF TIE APPLICATION OR REVOCATION OF ANY PERMIT GRANTED BASED UPON SAID APPLICATION AND IN LEGAL._ ACTION FOR PERJURY AS PROVIDED BY LAW. :'API 'LIGATION FEE X1.50.{0 JOHN UlWA-NER - F:EC`D BY LISA RAJ r +1 ' 07/!2/95 DATE 07/12/9 5 ONNi.•AGENT SIGNATURE DATE .-- :r. nr•. r n. - n,-r-.. .-,. - ...- -5��.r-Lr?' 1t.-'f\ iL r FORM NO. STATE OF COLORADO For Office Use only IECEjVr. 07/93 OWS-11 . , OFFICE OF THE STATE ENGINEER `� 818 Centennial Bldg.,1313 Sherman St.D«,v.r,Colorado eo203 FEB 2 2 (303)886.3581 2000 PRIOR TO COMPLETING FORM, SEE INSTR(1CTIONRE ON REVERSE SIDE -M...r WA1Eh,¶EaU�.�< CHANGE IN OWNERSHIP/ADDRESS I LOCATION STA'�o,, FN ,rt ' r•. WELL PERMIT, LIVESTOCK TANK OR EROSION CONTROL DAM 1. NEW OWNER NAME(S) D. Q.fY1G , ' • - Mailing Address � 1.Q.....Weld. Cam... gd City, St. Zip rr . L...L 4o.........�•. r...... ..C.t.�..s .1 Phone ( ) 2. THIS CHANGE IS FOR ONE OF THE FOLLOWING: � - ® WELL PERMIT NUMBER.............,_. 1 "!j ' c4 Q LIVESTOCK WATER TANK NUMBER ❑ EROSION CONTROL DAM NUMBER 3. WELL LOCATION: COUNTY UUI C— OWNER'S WELL DESIGNATION 1..45....8 c .). l`.a� CD. r� 4 b P . t__ lion TO.O (Address) (City) (ate) (ap) S., 1/4 of the.Ua2 1/4, Sec. Q Twp. I ©N. or❑S., Range,..,. 1 ❑E. or 14 W. ............. P.M. Distances from Section Lines ............. Ft. from❑N. or❑S. Line, Ft. from❑E. or❑W. Une. Subdivision Lot Block Filing (Unit) •- r 4ua.. 4. LIVESTOCK TANK OR EROSION CONTROL DAM LOCATION: COUNTY . ..... 1/4, Sec, Twp, ❑N. or❑S., Range ❑E. or❑W. P.M. 5. The above listed owner(s) say(s) that he (they) Otivri the structure described herein. The existing record Is being amended for the fold wii g reaeon(s): ® Change In name of owner. ❑ Change In mailing address. ❑ Correction of location. 6. I (we) have read the statements made herelk,Know the contents thereof, and state that they ere true to my (ow) knowledge. [Pursuant to Section 24-4-104 (13)(a) C.R.S., the making of false statements herein constitutes perjury 1n the second degree and is punishable as a class 1 ,riiisdemeanor.] Name/Title (New Owner) Please type or print Sigh` re (New Owner) Date RcDbe(+ U. ©rnQn i 67‘:6a FOR OFFICE USE ONLY ACCEPTED AS A CHANGE IN OWNERSHIP AND/OR MAILING ADDRESS.wommirromporpi-41(LI .a • 1, �� MAR 01 2000 State Engineer By Due Court Case No. Div. Co. WD n MD Use August 10, 1998 INSTRUCTIONS CHANGE OWNERSHIP-ADDRESS LOCATION CORRECTION FORM • . NO FEE IS REQUIRED The form must be typewritten or printed in BLACK INK. Initial and date any changes you make on the form. THIS FORM MAY BE REPRODUCED BY PHOTOCOPYING OR WORD PROCESSING MEANS. INCOMPLETE FORMS WILL BE RETURNED. ATTACH ADDITIONAL SHEETS IF MORE SPACE IS NEEDED. 1. The form is to be completed by the new owner. Print the new owner's name and include the mailing address and phone number. 2. Indicate if the change in ownership/address is for a well permit, livestock water tank or erosion control dam. Be sure to include the proper permit, tank or dam number. 3. Complete the well location information. If the address of the well location is different than the mailing address of the owner, include the address where the well is located. If the owner has more than one well, provide well name or number as designated by the owner; i.e. North Well. The actual well location must include 1/4, 1/4, Section, Township and Range. Check the appropriate boxes for North or South and East or West directions. Complete the Subdivision, Lot, Block and Filing"information, if applicable. 4. Complete the location information for the livestock water tank or erosion control dam. The actual location must include %, Section, Township, Range and P.M. Check the appropriate boxes for North or South and East or West directions. 5. Check the reason(s) for submitting the form, whether it is a change in ownership/address and/or location correction. 6. The owner of the structure must sign. Print or type your name in the first block if it is different from Item No. 1. If signing as a representative of a company who owns the structure, then your title must also be included in the first block. Sign the second block and date the last block. USE THIS FORM TO CORRECT THE LOCATION OF YOUR WELL IF: A. Your well was permitted, registered, or first used prior to May 8, 1972 for ordinary household purposes in up to three single-family dwellings, fire protection, the watering of poultry, domestic animals, and livestock on farms and ranches and the irrigation of not over one acre of home gardens and lawns. B. Your well is not of the type described in A above, but was permitted or registered prior to May 17, 1965. Inside the Designated Ground Water Basins, other procedures and publication may be required. C. Your well was decreed by the Water Court for the correct location. IN ALL OTHER CASES USE FORM GWS-42 If you have questions, contact the Denver or the Division Office where your well is located. DIVISION 1 DIVISION 2 Box 5728 DIVISION 3 Box 269 DIVISION 4 Box 456 800 8th Ave Rm 321 310 E.Abriendo Ave. Ste B 422 4th St 1540 E Niagara Greeley CO 80631 Pueblo CO 81004 Alamosa CO 81101 Montrose CO 81402 (303)352-8712 (719)542-3368 (719)589-6683 (303)249-6622 DIVISION 5 Box 396 DIVISION 6 Box 773450 DIVISION 7 Box 1880 DENVER OFFICE 50633 US Hwy 6&24 1120 So. Lincoln Ave Ste 101 1474 Main St Rm 821 Glnwd Spgs CO 81601 Stmbt Spgs CO 80477 _t Durango CO 81302 1313 Sherman St (303)945-5665 (303)879-0272 ._ '(303)247-1845 Denver CO 80203 (303)866-3581 FORM NO. PUMP INSTALLATION AND TEST REPORT For Office Use only GWS32 • ^ 10f94 STATE OF COLORADO, OFFICE OF THE STATE ENGINEER RECEIVED1. WELL PERMIT NUMBER J i 51 f �} // ��et- OCT 091996 2. OWNER NAME(S) .--O ki k‘.) p. 1.UQ -e)-- Mailing Address ??r S 1•.5 i•e �.lo W��ERRcS��+ E�J e. srr��o. City, St. Zip L_A-f< w a .L I CAN) cF 4 7 Phone (303 ) '6-p _ 0/qE 3. WELL LOCATION AS DRILLED: ,}'C- _1/4 A)L) 1/4, Sec..2P- _Twp. _ ,v , Range LJ Of. DISTANCES FROM SEC. LINES: Dc. ?D ft. from Sow 74 Sec. line. and a a Vd ft. from w�S Sec. line. (norm orb teas: wesrj SUBDIVISION: LOT BLOCK ---- FILING(UNIT) STREET ADDRESS AT WELL LOCATION: i 5/ (JC - Fr‘...4) ----(--d4 c p --�4 „rig-J/-7 4. PUMP DATA:Type S u b it c r s le Installation Completed 7 -- �_ '' Pump Manufacturer G , „id,. Pump Model No. /O rs • Design GPM 1 b at RPM , HP 3 , Volts , Full Load Amps Pump Intake Depth G if- Feet, Drop/Column Pipe Size / Inches, Kind GGc l pc, ADDITIONAL INFORMATION FOR PUMPS GREATER THAT 50 GPM: TURBINE DRIVER TYPE: El Electric ❑Engine El Other • Design Head feet, Number of Stages , Shaft size inches. 5. OTHER EQUIPMENT: Airline Installed❑Yes LNo, Orifice Depth ft. . Monitor Tube Installed ❑Yes No, Depth ft. Flow Meter Mfg. Meter Serial No. . Meter Readout❑Gallons,❑Thousand Gallons,❑Acre feet,❑ Beginning Reading . 6. TEST DATA: [ Check box if Test data is submitted on Supplemental Form. (( Date 3-.? p 1 Total Well Depth fa Time _ Static Level Rate (GPM) �Q Date Measured ,O,.- 3— A Pumping Lvl. _ 2G 7 7. DISINFECTION: Type /1-1(,/.- Amt. Used Pi /. ..5 8. Water Quality analysis available. El Yes ( 'Ico 9. Remarks 10. I have read the statements made herein and know the contents thereof, and that they are true to my knowledge [Pursuant to Section 24-4-104 (13)(a) C.R.S., the making of false statements herein constitutes perjury in the secon• degree and is punishable as a class 1 misdemeanor.] I CONTRACTOR /0 V P S I ' 1.0 Phone (?a? ) ,1�► 7-020 Lic. No(77CC T Mailing Address C.;o,. f - Name/Title (Please type or print) Signature Date INSTRUCTIONS FOR PUMP INSTALLATION REPORT The report must be typed or printed in BLACK INK All changes on the form must be initialed and dated. Attach additional sheets if more space is required. Each additional sheet must be identified at the top by the well owner's name, the permit number, form name/number and a sequential page number. Report depths in feet below ground surface. This form may be reproduced by photocopy methods, or by computer generation with prior approval by the State Engineer. Photocopy reproductions must retain margins and print quality of the original form. The original form must be submitted to the State Engineer's Office within 60 days after completing the well or 7 days after the permit expiration date, whichever is earlier. A copy of the form must be provided to the well owner. if this form is submitted in conjunction with the Weil Completion and Test Report, form number GWS-31, ONLY THE PERMIT NUMBER AND OWNER NAME NEED TO BE COMPLETED in items 1 and 2. 1. Complete the Permit Number in full. 2. Fill in Name and Mailing Address of Well Owner where correspondence should be sent. 3. Complete the blocks for the actual location of the well. For wells located in subdivisions the lot, block and subdivision information must also be provided. 4. Indicate the type of pump installed and complete the requested information. When installing pumps greater than 50 gpm, complete the additional information in this area. 5. Provide the information on other equipment which may be installed in the well. 6. Report test data as required by Rule 13.9. Spaces are provided to report all measurements made during the test. The report should show that the test complied with the provisions of the rules. If a test was not performed explain when it will be done. If available, report clock time when measurements were taken. 7. Record the type and the amount of disinfection used, how placed and the length of time left in the hole. 8. Indicate if a water quality analysis was performed and submit a copy of the report if available. 9. Use the remarks area to note any additional information including additional equipment installed, water supply construction problems. 10. Fill in Company Name and Address of Contractor who installed pumping equipment. The report must be signed by the licensed contractor responsible for the installation of pumping equipment. ' `^°" NO. ✓ PUMP INSTALLATION AND TEST REPORT rnr ratite !r.. w" Gus• 32 RECEIVEDI,»n. - STATE OF COLORADO. OFFICE OF THE STATE ENGINEER SEP� I WELL PERMIT NUMBER /Sy9�f` 7 1996 l WATER RESCA e.., 2 OWNER NAME(S)�dh h, (,��[rt C} — 6TATEENOMI�cA � � COW.f,tiiling Address qb- w .p .-.L.c y_ziscf- —._ .__-- city, St. Lift __I"6.11._k4 w_o7tlt. kcL2 1 ... . ----_. ____-- _.Lhone (3 d- ) g3:22=1.2- 3 WELL LOCATION AS_DRILLED 5.kr• 1/4 /3J pa 1/4. Sec _r. Twp __Lilt_ __ Range__L4 W 6 tam DIS rANCES FROM SEC LINES. f(Z_ ft. from Sqv th Sec line anti a9oyc) it. from GQ0.,St Sec. line Innelh n, yid^, Wr-OOr wnwr ,1JRr1IVISION• LOT RLOr''K _ _ --FIL1Nt'{UNIT1 . _ STfiEFT ADDRESS Al WELL t )CATION_ /q Sid wCMf hi' _Ff b,�D/i ) rat-a 8`447./ -- 4. Pr r'AP DATA:_Type _S 5,2,,.e,_- Lfp_j_Cr -- --- -,-- ..-__ Installation COmpieted 3 -e. — _— _ r.IaTTp Menlilaoturer 6G.ii. .d,____ - - _- _____ _ Primp Mnrtnt Nn 1(]_I;.\. --- --- - .- frr"aryl GPM /0 At PPM _ ___ .it' _ . Volts _ Frill I earl Ampsrnmp Intake Depth _(pr,� _ rpPt, Drrip/COIu irnn Prprn Siie f-4�y! - ---Irirhe5 v,rnt �i¢k L! I AnotripNAL INFORMATION F AR PUMPS_GREATER !VIA 50 M GP . T^.-ufRINE LIRNER TYPE E.3 glecIric Ll Engine (.-.1 Other Design 'lean teem, Nu r'nTtier of Stages Shaft size it 5 I OTHER EQUIPMENT: rotting installed❑Yes Lx 1 ph Cnrice Depth I1. . Monitor Tube installed ❑Yes I No. Depth ft ____ now Meter Mfg. —_ — __ Meter Serial No { Meter Readout ❑Gallons. ❑ Thousand Gallons. ❑ Acre feet, ❑ Beginning Reading - F. TEST .DATA: 12 Chem. hox if Test data is submitted on Supplementar Form Date -_3-= 2-91' ---- ---- -- Total Welt Depth fg"-0 Time yPM Static: Level _-_ J 3 3 Rate ((FPM) _ /5_____ Date Measured 1.4 -I P Pu,ntping Lvt. > 6 7 7 DISINFECTION! Type 11J Amt Used m ,1 -.S R. Water Quality 8nalysiS 2vailahPa ❑ Yes [iii No !I nem:Irks '1n. I have read the statements rngoe herein and know the contents thereof. and that they are tnre to my knowledge �Pirrsiiant to Section 2,1 4 10.1 111.H1) C 11 S , the making at false statements herein cn'rctrrutes perjury in the seconr1 degree anti is prrnishrot)lr~ rig a ^lass I misdemeanor j CONfPACTOn 1.e2 S -. 171_l N N i Phone r.3C?31 7 =c).c (/ Lie No f�Aadir rt Aclr[rL'SS v -�-. .� �� IIlarnp;T.tle (Please type or print) �ignaturp ---- Date D� 1-A et)1,_&_,L1).O11 e�._ Rai, e ,� ^-- �r a a `f‘, Best Copy Available FORM NO. V WELL CONSTRUCTION AND TEST REPORT For orrice use only } Gus-31 STATE OF COLORADO, OFFICE OF THE STATE ENGINEER Ilion RECEIVED I. WELL PERMIT NUMBER J/ / 7 2. OWNER NAME(S) 2 SEA 7 1996 Mailing Address PS Q WATER aESOL14C S City, St. Zip )-. AC e W 0 b j C r� b o -ate STATE cotAw a Phone (3Q3 ) `f_9 — CIA/ q_. • 3. WELL LOCATION AS DRILLED: S'E--• 1/4 Y11 1)31/4, Sec.,1E-7 Tfwp.J , Range4 0 A, DISTANCES FROM SEC. LINES: 6 9a_ ft, from S'd ti-fk, Sec. line, and a no ft. from (,a1? _Sec line. OR Inordt or anuth) toast or ., sr) SUBDIVISION: LOT BLOCK FILING(UNIT) STREET ADDRESS Ar WELL LOCATION: - -__- ' - 4. GROUND SURFACE ELEVATION ft. DRILLING METHOD IP Q),y DATE COMPLETED 3-a--yb . TOTAL DEPTH 9Tro ft. DEPTH COMPLETED 9S'O ft. S. GEOLOGIC LOG: 6. HOLE DIAM. (in.) From (ft) To (ft) No, p�� P pescriprinn of Materiel (type, ixn, Coln+ 'tinter Lcentlnn] �` _ �,- !rS V 1 S a t S-11+ �- -------- ---------- ------1- tv Y a-lut 7. PLAIN CASING 65— S y — ,s,0r�C_ J - t _Sg,,s _ OD (in) Kind Wall Size From(f%) To(ft)Lt:c, 2D _.5h - Sg- S pt1 e_ 54 SYdok r 1 kr p 8b G o _ "ss- . - h,-/--te DI-1-- t4-Ia -S fi- r.oc ti� eSr-- Lid S' -t-oC./J�- „5�A-I e PERF. CASING: Screen Slot Size: 40 s _ i sY.4h ,/f1 Ph 98a o-- 5/ Ca -5 t4-1a /- cL 6 -^ eL- - 1-c -J - f .5- a D .S ,pr c - cam.f_ S ,9-1P (fir -750 S 0.../e_ 8. FILTER PACK: 9. PACKER PLACEMENT: 7 0 - oG -C o t r e — Material Type 3 - S' NJ _oa s 0-le - co4/._ ,Se rs Size 35-- f4 jrot -5 h,g/e-SA&d —Coq. I x Interval Depth _ S-46-- q _—t^_6r 1_.S 4!�1 e- S k tick--3171I€ �htrt qE_ 10. GROUTING RECORD: FM.: *PD S,9-/e. '4_g -----C—;— pf...f ,ye ty lentil Amount Density Interval Placement �REMARKS: 1s/.4,,/ .55sp'-4,_2aots4 O -Woo pos dn.-I D91. Best COPY Available — - — II DISINFECTION: Type jot/A Amt. Used . /U ,t;,hS 12. WELL TEST DATA: bYlCheck box if Test Data is submitted on Supplemental Form. TESTING METHOD 504-19-,.s ii tl?, Static Level )3 3 ft. Date/Time measured a-7- 7e, 7,411/1 , Production Rate 1-5 grim. Pumping level o{,7 ft. Dale/Time measured :; - 1 _q�, r'0 , Test length (hrs.) .1 Remarks 13. E have rend the staternnnte made herein rind Frrow the contonIa thereof,and that they are true to my knowledge [Pursuant to Section 24-i-$04 (13)(e)C S• the making oI rnlse slretementa herein consrin..tee perjury in the second degree end le punishable an a claaa 1 misdemennor,[ CONTRACTOR 6,1-eve)--V ,/� W 4 /4/9 Phone a(jp_3) Fj 7- �7Oi/J Lic, No.bf. Mailing Address 7,2.0/ GJ .q, p/- ,(,x,4O7., 03 ti D Fob 31-1.15-1) Nanne/Tiile (Please type or print) Signature Date /l -e.s-- a,r c - `� d d `,Y INSTRUCTIONS FOR WELL CONSTRUCTION AND TEST REPORT r r Tire sport Must he typed or printed in BLACK INK, All changes on the form must be initialed and dated. Attach pdrtitional sheets if more space is required. Each additional sheet must be identified al the top by the well owner's name, the permit ni mher, lorm name/number and a sequential page number. Report depths in feet below ground :;urlace. This form may he reproduced by photocopy methods, or by computer generation with prior approval by the State F ngineer. The original and one copy of this form nut be submitted to the State Engineer's Office within &) days after completing lire well or 7 days after the permit expiration date, whichever is earlier. Another copy of the_form must tie provided r r the well owner. I. Complete the Well Perrnit Nrunlx'r in full. 2. Fill in Name and Mailing Address of Well Owner where correspondence should he sell? a C-urr,plete fire blocks for lire actual location of the well where drilled If the owner has more than one wall senvind this property, provide the identification (Owner's Designation) for this well. DO_NOT USE THE OWNER SUPPLIED LOCATION unless a survey has been provided. For wells located in subdivisions the lot, block and subdivision information must also be provided. 4. Report the ground surface elevation in feet above sea level it available. This value may be obtained trorn a topographic map. Describe the drilling method used to construct the well and the date completed. Indicate the total depth drilled and the actual completed depth of the well. 5. Fully describe the materials encountered in drilling. Do not use formation names unless they are in conjunction with a description of materials. Examples of descriptive terms include: Grain size-.Boulders, gravel, sand, silt, clay. Hardness-Loose, soft, right, hard, very hard. Color--All materials. Most critical in sedimentary rock. Depth when water is encountered (if it can be determined). Provide the diameters of the drilled bore hole. 7. The outside diameter, kind, wall thickness and interval of casing lengths must be indicated. 11. Indicate the type and size of filter (gravel) pack and the interval where placed. ��. Indicate the type and setting depth for any packers installed. '0. Tire density of the grout slurry must be reported and may he indicated as pounds per gallon, gallons of water per sack, total gallons of water and number of sacks used, etc. Specify the grout placement method, i.e- tremie pipe or positive displacement. The percentage of additives mixed with the grout should be reported under remarks. s t. Record the type and the amount of disinfection used, how placed and the length of time lett in the hole I?. Report well lost data as required by Rule 10.7. Spaces are provided to report all measurements made during the test. The report should show that the test complied with the provisions of the rules. If a test was not performed explain when it will be done. if available, report clock time when measurements were taken. 13. fill in Company Name and Address of Contractor who constructed the well. The report must be signed by the licensed contractor responsible for the construction of the well. Form No. OFFICE OF THE STATE ENGINEER GWS-25. .COLORADO DIVISION OF WATER RESOURCES 818 Centennial Bldg., 1313 Sherman St., Denver, Colorado 80203 (303) 888.3581 403 WELL PERMIT NUMBER 'jS49SG - -- APPLICANT DIV. 1 CNTY. 62 WD 2 DES. BASIN MD Lot: Block: Filing: Subdiv: APPROVED WELL LOCATION WELD COUNTY JOHN D WAGNER SE 1/4 NW 1/4 Section 28 9885 W WESLEY AVE Twp 1 N RANGE 66 W 6th P.M. LAKEWOOD CO 80227 DISTANCES FROM SECTION LINES (303)980-0495 2690 Ft. from South Section Line 2040 Ft. from West Section Line PERMIT TO CONSTRUCT A WELL- CONDmONS OF APPROVAL 1) This well shall be used in such a way as to cause no material injury to existing water rights. The issuance of the permit does not assure the applicant that no injury will occur to another vested water right or preclude another owner of a vested water right from seeking relief in a civil court action. 2) The construction of this well shall be in compliance with the Water Well Construction and Pump Installation Rules 2 CCR 402-2, unless approval of a variance has been granted by the State Board of Examiners of Water Well Construction and Pump Installation Contractors in accordance with Rule 17. 3) Approved pursuant to CRS 37-92-602(3)(b)(Il)(A) as the only well on a tract of land of 40 acres described as the SE1/4 of the NW1/4 Section 28, Township 1 North, Range 66 West of the 6th P.M.. 4) The use of ground water from this well is limited to ordinary household purposes inside three single family dwellings, fire protection, the watering of poultry, domestic animals, and livestock on farms and ranches, and the irrigation of not over one acre of home gardens and lawns. 5) Production from this well is restricted to the Laramie Fox-Hills aquifer which corresponds to the interval between 860 feet and 1120 feet below ground surface. Plain casing shall be installed and sealed to prevent production from other zones. 6) The maximum pumping rate shall not exceed 15 GPM. 7) The return flow from the use of the well must be through an individual waste water disposal system of the non-evaporative type where the water is returned to the same stream system in which the well isl�. 8) This well shall be constructed not more than 200 feet from the location specified on this permit. ,,---ct Note: To insure a maximum productive life of this well, perforated casing should be set through the entire producing interval of the approved zone or aquifer indicated above. APPROVEDlia hh RAN .tl _//t ( ",,,, slaw.EngineerReceipt No. 0379791 DATE ISSUED F E B 1 5 1995 EXPIRATION DATE FEB 1 5 1997 Ir WRJ-s-Ref,,. 76 - COLORADO DIVISION OF WATER RESOURCES 818 Centennial Bldg., 1313 Sherman St., Denver,Colorado 80203 / PERMIT APPLICATION FORMCEIVCr qgApplication must 'J be complete where (e.<) A PERMIT TO USE GROUND WATER all 3 / applicable. Type or (JO A PERMIT TO CONSTRUCT A WELL print in BLACK FOR: ( Ali!, PERMIT TO INSTALL A PUMP ` un .: INK.No overstrikes � } or erasures unless ( 1 REPLACEMENT FOR NO. initialed. ( ) OTHER WATER COURT CASE NO. (1) APPLICANT - mailing address FOR OFFICE USE ONLY: DO NOT WRITE IN THIS COLUMN NAME 7o '` ) O. LL)f ( 5 n C' v Receipt No.3 7 979/ / RAW STREET `� PPS - L)- &) eS)e r V�. _ Basin Dist. CITY L l4 Kn.'ei CO. d 0,27 (State) (zip) CONDITIONS OF APPROVAL TELEPHONE NO. 2 03 9 8O "' 0 '(9 S This well shal4 be used in such a way as to cause _ no material injury to existing water rights. The (2) 1,O-CATION OF PROPOSED WELL issuance of the permit does not assure the applicant that no injury will occur to another vested water right or preclude another owner of a vested water County ' e 1.1 right from seeking relief in a civil court action. r� a-Ki No S4Li F %+ of the N W 'b, Section g d' 3.690-5 Twp. S k, Rng. fo C P.M. -r.1s.�.. IN.S) (E,W) 4 0 (3) WATER USE AND WELL DATA so{S T- Proposed maximum pumping rate(gpm) IC '-c LAN Average annual amount of ground water L, 4 a. to be appropriated (acre-feet): to 3 1..e Number of acres to be irrigated: Proposed total depth (feet): 966 Best Copy Available Aquifer ground water is to be obtained from: I'o 1-71 ; LL . Owner's well designation GROUND WATER TO BE USED FOR: ( I HOUSEHOLD USE ONLY - no irrigation (0) ( DOMESTIC (1) ( ) INDUSTRIAL (5) LIVESTOCK (2) ( ) IRRIGATION (6) ( } COMMERCIAL (4) ( ) MUNICIPAL (8) { ) OTHER (9) - APPLICATION APPROVED DETAIL THE USE ON BACK IN (11) • PERMIT NUMBER (4) DRILLER ((}} DATE ISSUED Name r�!'� U y e r SC' h O c kJ c EXPIRATION DATE_ Street "1 k 2 S r ) b ) O.,., Q b CHECKS TRN379791 011395 60.00 � `4 6�� v DI OF WATER RESOURCES 1 City I . ? A I tr r t Ct f( C 0 0 (STATE ENGINEER) (State) (ZIP) BY Telephone No. D-Pf' C`( 7 t/ Lic. No. U 0 3 0 I.D. / COUNTY , 1 (5) THE LOCATION OF THE PROPOSED WELL and the area on (6) THE WELL MUST BE LOCATED B OW which the water will be,used-must � indicated on the diagram below. , by distances from section lines. 6" Use the CENTER SECTION (f section, 640 acres) for the well location. + --- —I- — + — +. — •— + a 6 SrQ _ft, from (north ) sec. line .i- I MILE.5280 FEET-----).1 # -,,,a O Li U ft.from_ 0.)• e Sfi _ sec. line (east or west) + + + + - + LOT BLOCK. FILING a` I I I I SUBDI VISION NORTH SECTION LINE , + — I (7) TRACT ON WHICH WELL WI.L BE LOCATED Owner, 4-o kw 0. CO o-5-1,a NORTH II T z — — — + — m + t No. of acres ') t-IO . Will this be J H • O I I w p m the only well on this tract? (Tied' t 0 IC n z + (8) PROPOSED CASING PROGRAM I H I— Plain Casing W 2 ll __ m + T G % in.from2:__1_____ft. to -I 7 ft.I I I �-in.from i O ft. to O 0 ft. -4-- _ _i_ - — ._ — Perforated casing SOUTH SECTION LITIE � I I I I u/' J in. from -1 D U _ft. to CI 0 0 ft. + + + + —1- + 4 + + . in. from _ ft. to; -, ft. J I I I (9) FOR REPLACEMENT WELLS givedistance and direction from old well and plans for plugging -(- __ I._ - + - + -- 4- - --i_ - - 4_ it: The scale of the diagram is 2 inches= 1 mile N A Each small square represents 40 acres. WATER EQUIVALENTS TABLE Mounded Figures) - An acre-foot covers 1 acre of lend 1 toot deep 1 cubic foot per second Icls) ...449 gallons per minute(ppm) A family of 5 will require approximately I acre-foot of water per year. 1 acre-foot ...43,560 cubic feet. . .325,900 gallons. 1,000 gpm pumped continuousfy for one day produces 4.42 acre-feet. ti (10) LAND ON WHICH GROUND WATER WILL BE USED: Owners):-�I � CA)-f� h Y r _ _ No. of acres: Jab , Legal description: "•••••C /8 C7 4_, N (.11 �QE S e t�� t Y1 I N 11, n q g 6 L' O 1 hL L p7n (11) DETAILED DESCRIPTION of the use of ground water: Household use and domestic wells must indicate type of disposal system to be used. i( e G J r"!`£1 1 (12) OTHER WATER BIGHTS used on this land, including wells. Give Registration and Water Court Case Numbers. Type or right Used for (purpose) Description of land on which used 1\E Pr \(13) THE APPLICANT(S) STATE(S) THAT THE INFORMATION SET FORTH HEREON IS . TRUE TO THE BEST OF HIS KNOWLEDGE. SIGNATURE OF APPLICANT( )1' 77I-D' o-� Use additional sheets of paper if more space is required. EXEMPT WELL DATA SHEET - DENVER BASIN, COLORADO APPLICANT: WAGNER RECEIPT NO. 379791 LOCATION: SE1/4 OF NW1/4 OF SEC. 28, T.1N., R.66W. (2590 NSL, 2040 WSL) PROPOSED AQUIFER: LARAMIE-FOX HILLS SURFACE ELEVATION: 5055 NUMBER OF ACRES IN TRACT: 40 IS PROPERTY WITHIN SERVICE BOUNDARIES OF MUNICIPALITY S.B.5 CONSENT MAPS? NO_ YES IF SUBDIVISION IS UNDER AUGMENTATION PLAN, CASE NO. IS , DIV. IF SUBDIVISION WAS RECOMMENDED FOR APPROVAL BY THE WATER MANAGEMENT BRANCH, DATE OF LETTER IS INFORMATION ON SUBDIVISION OR TRACT OF LAND/SPECIAL RESTRICTIONS: evaluated by RAN on FEBRUARY 2, 1995 ELEVATION DEPTH TO ANNUAL NET APPROP STATUS AQUIFER BOT. TOP SAND SOT. TOP A-F UPPER DAWSON --- -- - - ---- -- -- LOWER DAWSON - DENVER ---- - -- -- ---- - - -- UPPER ARAPAHOE 4870 4890 8 185 165 0.476 E NT LOWER ARAPAHOE 4564 4802 99 491 253 6.664 NNT *LARAMIE-FOX HILLS 3937 4194 184 1118 861 11.040 NT note: E indicates Location is at aquifer boundary and values may be more approximate. * indicates the proposed aquifer. All values are interpolated from the S.B.5 data base assembled in November of 1986. M Fwd: Fw: well permit no. 184986 1 message Keaton Crawford <keaton.m.crawford@gmail.com> Thu, Mar 12, 2020 at 9:48 AM To: Elyse Dinnocenzo <elyse@principlelandplanning.com> Here is the letter from state water explaining that they do not specify the animals that they consider domestic. Let me know if you need anything else from me at the moment! Thank you! Forwarded message From: Rachel Crawford < Date: Wed, Mar 11, 2020 at 2:54 PM Subject: Fw: well permit no. 184986 To: < > From: Grimes - DNR, Chris < Sent: Wednesday, March 11, 2020 2:31 PM To: < Subject: well permit no. 184986 As discussed over the phone today, the well with permit no. 184986 (attached) is currently permitted to be used for domestic purposes inside three homes, the watering of domestic animals and livestock, and the watering of up to 1 acre of home gardens and lawn. The well is not currently permitted to be used for any commercial purposes (excluding raising and grazing of livestock on farm/ranch); it is strictly to be used for those home/residential purposes described on the permit. The law does not describe specifically what domestic animals and livestock are (rather statute only gives a few as an example), nor does it define what domestic animals can be served by a well. Therefore, it is our opinion that the well with permit no. 184986 could be used to supply water to any number of species provided the animals are not part of commercial enterprise (zoo or other business) In the future, if the well owners would like to use the well for residential AND commercial purposes, the well permit will first need to be changed. This change will likely require an augmentation plan for approval, and a water attorney and consulting engineer will likely be needed to develop such a plan. Please see information about augmentation plans here: Chris Grimes Ground Water Commission Staff CCOLORADO .... ell Division of Water Resources T]epart_-nent of Natural liesources P 303.866.3581 x 8253 chris.grimes@state.co.us / www.water.state.co.us Hello