HomeMy WebLinkAbout20194979.tiffWATER SUPPLY INFORMATION SUMMARY
Section 3O.2B•I33.tdj. C.R.3 requires diet the *plait *knit to the County,'Adegeat. warm that a water supply that
as wifeiont +e terms of quantity. gait] sad litilreadabirrty will be available to otta re an adequate supply of water.
1. NAME OF DEVELOPMENT AS PROPOSED
rod
2. LAND USE ACTION
3. NAME OF EXISTING PARCEL AS RECORDED
SUBDIVISION FILING
BLOCK LOT
4. TOTAL ACREAGE 10
1
S. NUMBER OF LOTS PROPOSED
PUT MAP ENCLOSED 0 YES
6. PARCEL HISTORY - Please attach copies ef deeds, plats sr ethic miasma exdessenentaties.
A. Was purl recorded with county prier to June 1. 1972? (AS O NO
B. Has the parcel ever bee. part of a division of land action sacs June I, 1972?
11 Iwo. Moab* the pra sus aetiaa r7/3A• � T
0 YES Milli
7. LOCATION OF PARCEL - Male a map deiaiating the project area and tie to a saetien corner.
5 114 OF CCJ 114 SECTION TOWNSHIP I k @-f(❑ S RANGE Q E OW
—
PRINCIPAL MERE dIN ❑ fs.M. 0 UTE ❑ COSTILIA
8. PLAT - Location of aB wells on property mast be plotted and permit numbers provided. 1Lt
Swayers plat ❑ Yes O N. If not, scaled hand drawn sketch 0 Yes O No
9. ESTIMATED WATER REQUIREMENTS - Wont per Orr et Atm Feet par Year
HOUSEHOLD USE If of units
GPO AF
COMMERCIAL USE P of S.F. GPO Af
IRRIGATION / of ices GPD AF
STOCK WATERING 1 of had GPD AF
OTHER GPO AF
TOTAL GPO AF
EztabfOici l&rI 1s tilititatOyu �
10. WATER SUPPLY SOURCE
❑ EXISTING 0 DEVELOPED
WELLS SPRING
WELL PERMIT NUMBERS
Q MUNICIPAL
❑ ASSOCIATION ac�
C PANY Pe
c4-
00301(2-0,
NAME Cusitired.ta1d
LETTER OF CO NITWIT FOR
SERVICE 0 NO
a NEW WEALS -
rarwm sawn. - cur are
❑ .uu,rt
o tem steam
UM eviler
..1 ettir�
u anon
o WEN AhIPIAX
G tamer UMW
o MAIN In MIS
MUM
WATER COURT DECREE CASE NO.'S
37
V
-s'
11. ENGINEER'S WATER SUPPLY REPORT 0 YES 0 NO IF YES, PLEASE FORWARD WITH THIS FORM. Mil soy It maul Inkye ever mire s cw*td1
12. TYPE OF SEWAGE DISPOSAL SYSTEM
-3rY7S
T CR FI1=tD
IC
❑ LAGOON
sF f LOCO at; Ld,irY
0 CENTRAL SYSTEM DISTRICT NAME
Pg9UC52�t O VAULT • LOCATION Sl1NAGE HAULED TO
sa--t QOC ? \r�.,.�
Meter Readings Read Dates
Read Code Previous Present c0
previous Present Usage
Ac031 Number Description 4066 4116
50 Actual 05/22/2019 06/19/2019
003x016 --fit 1000 Gallons
Previous Balance
Water Minimum Charge
Water Usage Charge
CBT Surcharge
Multiple Unit Surcharge
$66.60
$16.50
$62.70
$0.00
$7.00
Please write account number on all payments and correspondence.
You may pay your bill at www.cwcwd.com
Water
Total Current Charges $86.20
Total Amount Due $154.84
Customer
Troy D & Judy K Hefner
Billing Date
06/25/2019
l
DueData
07/15)2019
300
Central Weld County Water District
2235 2nd Avenue
t C MAMJ Greeley, CO 80631
(nA
Account Number
003016-01
Amount Due
$154.80
Annual Allocation YID Usage
265
-.. L.+ Telwcu rioter
?AA NO. 1'W f Nfn P. r : 1/0D1
Revised 4/30196
ACTS TAP*
TAP FAGREEMENT //��
THIS AGREEMENT, made and tntercd into this -/dayy of i2e ( nt .20 Og,
by and between the CENTRAL WELD COUNTY WATER DISTRICT, hereinafter called the Drier et, and
& Judy K. Hem hereinafter called Customer,
W1'1NESSETH:
WHEREAS, District has been organized as a legal body and is known as the Central Welt County
Water District, and
WHEREAS, 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 mum 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 l6
Seventeen Thousand. five lrtmdred & >
a.
17.500.00
2. The description of the premises for which this tap.is being icanciased is as foams:
The E 'A of the W'/i of the SE '4 of the SW '/. of Section 23, Township 1 Nosb, Range 68 Wept of the
6e p.M., County of Weld, State of Colorado
3. This agreement, when approved by the Board ofireciors, 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
contracted by District District shall be responsible for restoring surface area beck 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:
Capital Improvement Fee -- $4,000.00
Installation Fee - $6,950.00
7. Customer further' agrees to abide by the rates established and the rules and regulations: of the
District.
Tel WITNESS WHEREOF, the parties hereto have hereunto and hereunder set their signatures :he day
and year first hereinabove written.
CUSTOMER SIGNATI E C1✓N7RAI, WELD COUNT WATER DISTRICT
(Property Owner)
alldee/4*
BY
ATTES
WELD COUNTY BOARD OF HEALTH
ENGINEER DESIGNED SYSTEM REVIEW
▪ PROPERTY OWNER: Troy and Judy Hefner PERMIT NO.: SP -1100033 (New)
LEGAL DESCRIPTION: PT: SECTION: 23 TOWNSHIP: 1N RANGE: 68W
SUBDIVISION: LOT: BLOCK: FILING:
-- SITE ADDRESS: 4343 CR 6, Erie, CO -
- FACILITY: Commercial, 8 workers at 20 GPD and 20 customers at 5 GPD for a total of 260 GPD
— ACRES: 10
- PERC RATE: 9.72 mpi SOIL: Suitabfe WATERSUPPLY: Central Weld Water District
LIMITING ZONE: greater than 8 ft.
XXX ENGINEER DESIGN (3.5) EXPERIMENTAL DESIGN (3.14)
r•
ENGINEER: Alpha Surveying Co— l cil Crowe, P.E.
ADDRESS: P.O. Box 392, Fort Lupton, CO
ESTIMATED FLOW: 260 G.P.D. average daily flow, 390 G.P.D. maximum daily flow
— PRIMARY TREATMENT: Standard tank CAPACITY: 1000 gallons
` DISPOSAL METHOD: Absorption Bed SIZE: 452 square feet
- STAFF COMMENTS: The system is adequately sized for the proposed load.
STAFF RECOMMENDATION: Approval
ENVIRONMENTAL PROTECTION SPECIALIST: Lauren Light
REVIEWED BY BOARD: March 22, 2011
B.O.H. DECISION: APPROVED: " DENIED: TABLED:
Y
Chair!
Weld County Board of Health
WELD COUNTY DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT
1555 NORTH 17TH AVENUE
GREELEY, CO 80631
PHONE (970) 304-6415 FAX (970) 304-6411
Permit #: SP -9900524 Sec/Twn/Rng: 23 01 68
Owner: MILLER JERRY DEAN & CORTNEY ILEA
Applicant: MILLER JERRY
Permit Type: RNEW Commercial, R=Residential +NEW, REPair, VauLT
Parcel #: ' I y Ld"} 13 Q S"
Location: 4343 WCR 6 ERIE 23-1-68
Legal Description: 24925-C E2W2SE4SW4 2
(.25R1D)
Installer:
3 1 68 EXC UPRR RES
Status:
Applied: 10/11/1999
Issued: 10/13/1999
Finaled: J RIA 911 9f
Description: HOUSE
Commercial: Y
Residential: N Acres:
_
# of Persons: 3 Basement Plumbing: Y
# of Bedrooms: 3 Bathrooms - Full: 2 3/4:_ 0 1/2: 1
Water Public: N Water Source:
Water Private: Y Cistern: N Well: .X Well teanit #:
Percolation Rate:9.7 Limiting Zone: 8 ft (kin Description
% Ground Slope: 0 Dir: Soil Suitable: (Y/N) Y
Engineer Design Required: (Y/N) N In 100 Year Flood Plain: (Y/N) N
t'
Minimum Installation
Septic Tank: 1000 gallons Absorption Trench: 522
or Absorption Bed: 711
10
square feet
square feet
Actual Installation
Septic Tank: 1zc gallons Absorption Trench: szz square feet
Absorption Bed: square feet
Design Type:
Chambers
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 1{?, 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 not transferable. 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 was contingent upon the
final inspection of the completed system by the Weld County Department of Public Health and Environment.
X
• -
En ' nmeritill Health Specialist
t2-zcl—
Frnm: S_FINAL
Date
Accela Automation: GetPerSet250 - 8150-S
Page 1 of 1
Weld County, Colorado
usrID: MSWAIN
Menu ! Faycrkts ! FPO I 1.004,4 *Health
I_4„artlianager App4cationi Property 1 People Foes 1 tsshl8. Workflow Attachrre'Ri
4ppileatian - Summary
Application Type: Heater / EHS History / ENS Ceev0 Pon Fhstory F NA.
Application: G19880014
Owner Name: GREEN ROBERT
Owner Address; .1343 WCR 6. ERIE. CO B0516
Address: 4341 CRS. WELD, CU
Application Comments:
Application Status:
Parcel Mo-;
File Data:
Description o/ Work:
Application Spot Info.:
Application Spec Info. Table:
(.:cti gociti}
Finaled
140703
O 0/01/1988
OO.JRLE *WE TRAILER
S ass Information
Eng Design Req'a:
FEE PAID:
Filing:
Final Data:
Final Date Tenn.
Installer:
Issued Date:
Issued Text
Location:
Lot Steer
Owner/Agent:
INIRAIIT FEE;
Parc Dote:
Permit No:
Sec/Ton/Rngl:
Sac/Ton/Rn92:
SeclTwn/Rns3:
Signed Date;
Signed Date Te:rti
Status.
System Type:
Typer
Tear:
N
S
000
U2/ 1611988
0324
0023
02101/1988
0303
4343 WCR 6 ERIE CO 80116
10
ROBERTO. G$EEN
100
0210S/19884''
14
23
01 •
68
03/01/ 198a
0027
A
R
1988
Services/Installation
s of Bedrooms: 3
a of Persons; 3
eatermant ptrnobW'g:
Barbrooms:
Bed:
Bed Size SQFT:
Commerrlal:
Descriptions
-reuse sage:
Ipseltetlon:
Other:
Percolation Rata:
ResldeM1alt
Soli Suitable tar/u2;
Tank Cepachy Gel,
Trench.
Trench Sloe SQFT:
water Depth:
Water Supply:
Application Detail: D5 ii
Contact Info:
Licensed Professionals Info-:
Job Value:
Total Fee Assessed:
Total Pee Involved:
Balance:
Workflow Status:
Condition Status:
50.00
10.00
50.50
50.00
Task
N3
Condition Mama
N
2
1164
N
UO128Lt3 TI/PE TRAILER
H
N
45.002
Y
s
1000
Y
900
008
PWELL
Status
-fOR, 1 ACCRA AU10N.ATI0W
'Inspect ' 1 AecOrtS 1 Preference Project l Cardillo:,
C -
Status
Status Date
AWN Ds(.
let;S
UC,f. j
Action Ss
Severity Action Sy
hops:f/accela-web.co.weld.co.us/operations/permit/index.c fm?FUSEACTION=GetPeTSet2... -1 2/1/2009
19 Fg9009
DOCUMENT: STATEMENT OF EXISTING
DISKETTE: HPS2B
STATEMENT OF EXISTING SEPTIC SYSTEM
(Fill out in ink)
OWNER OF RECORD:
MAILING ADDRESS: 9'2'79 41,1C 1?-4-
C
SITE
ADDRESS: 4?PJ ACA
PHONE: ((S' s8''
LEGAL DESCRIPTION: PI,E4- 103' P2'F 14sec ) 3 TWNSP _
Subdivision:
/00
Bedrooms 2 Bathrooms
Use type
RNG C P
Lot; Block: Filing:
Water- Supply
Lqt Size /
Acres
SYSTEM SIZE: Tank is constructed. of..? ��� and has / d o gals capacity
a ma tetiaqrowill .
ABSORPTION BED: Sq. Ft. Total Date System Installed /9'..p.14,---
You are required to draw a diagram of the system on the reverse side of this form and
indicate position, 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 description, and further states that the system is in good
working order and to the best of his/her knowledge is not failing to function properly.
I further 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 prejury as provided by law.
ate
Subscribed and sworn to before me this
by.
/(7liner7i 2 . 6 e9ri
witness my hand and official seal.
Q.4./
ate
,d -d -411n411)112
day of
k-Avelt7
My commission expires 7vn e 2 /!
Notary Public
, 19(1
GRANTED
It is hereby ORDERED that upon
receipt of this order the moving party
shalt mail or deliver a copy to any pm
se party who has entered an appearance
in this action.
DISTRICT COURT, COUNTY OF WELD, STATE OF
COLORADO
Court Address: 901 9th Avenue
Greeley, Colorado 80631
IN THE MATTER OF THE MUNICIPAL
SUBDISTRICT, NORTHERN COLORADO WATER
CONSERVANCY DISTRICT
qzmu
James Hartmann
District Court Judge
DATE OF ORDER INDICATED ON ATTACHMENT
EFILED Document —District Court
I 937CV9454
LU Woo Lount7Uistrict Lauri MB iii
Fling Date: Jan 152013 06:40AM MST
Filing ID: 48922828
A COURT USE ONLY A
Case Number: 1937CV9454-S I
Div.: 1 Ctrm.:
ORDER FOR CONDITIONAL INCLUSION OF LANDS WITHIN THE
BOUNDARIES OF THE MUNICIPAL SUBDISTRICT, NORTHERN COLORADO
WATER CONSERVANCY DISTRICT
This matter comes on regularly before this Court on this day of
2013, on the Motion of the Board of Directors of the Municipal Subdistrict, Northern Colorado
Water Conservancy District ("Subdistrict") for an Order that the hereinafter described lands shall
be conditionally included in the Subdistrict. The Court, having considered said Motion and
being advised of the premises, fmds as follows:
I. Pursuant to C.R.S- §§ 37-45-120 and 37-45-136(2), as amended, certain owners of
lands Troy Hefner and Judy Hefner ("Petitioners") have filed with the Board of Directors of
the Subdistrict ("Board") a Petition in writing requesting that such lands be included within
the Subdistrict ("Petition"), which Petition described the tracts of land owned by the
Petitioners and is acknowledged as conveyances of land are required to be acknowledged.
2. The Petitioners and the lands sought to be included are set forth in Exhibit 1
attached hereto and incorporated herein by reference.
3. The Secretary of the Board caused notice of filing of the Petition ("Notice") to be
given and published in Weld County, Colorado, in which said lands are situated, which
Notice stated the filing of the Petition, the names of the Petitioners, descriptions of the lands
to be included, and the request of the Petitioners, and notified all persons interested to appear
at the office of the Board at the time stated in the Notice and to show cause in writing, if any,
39@5899 Pages: 1 of 4
01/28/2013 11:28 AM R Fee:$26.00
Steve Moreno, Clerk and Recorder, Weld County, CO
Ctrtined to
ccpy ct theegyr p-
vrre t
V.
s�
ti114611( „ # Al.
3 v
56110
•
PETITIONERS
Troy Hefner
Judy Hefner
DESCRIPTION
A tract of land situated in Section 23, Township I North, Range
68 West of the 6tb P.M., County of Weld, State of Colorado
described as E%xW%2SE%SW'/,.
10 Acres
Exhibit 1
3
3905899 Pages: 3 of 4
01/28/2013 Stev* Morre o,tClerB and Recorder, AM R ZWeld County, Co
/X111i����i'�1' ,�I�9.1�4�tii00,4L4iWIESh Iig IN I
GRANTED
It is hereby ORDERED that upon
receipt of this order the moving party
shalt mail or deliver a copy to any pro
se party who has entered an appearance
in this action.
DISTRICT COURT, COUNTY OF WELD, STATE OF
COLORADO
901 9th Avenue
Greeley, Colorado 80631
IN THE MATTER OF THE NORTHERN COLORADO
WATER CONSERVANCY DISTRICT
L'
James Hartmann
District Court Judge
DATE OF ORDER INDICATED ON ATTACHMENT
EF1LED Document— District Court
I937CV9454
Co Weld County District Court 19th JD
Filing Date. Jan 15 2013 06:40AM MST
Filing ID: 48922826
A COURT USE ONLY A
Case Number: 1937CV9454
Div.: 1
ORDER FOR CONDITIONAL INCLUSION OF LANDS WITHIN THE BOUNDARIES
OF THE NORTHERN COLORADO WATER CONSERVANCY DISTRICT
This matter comes on regularly before this Court on this day of
2013, on the Motion of the Board of Directors of the Northern Colorado
Water Conservancy District ('Northern Water") for an Order that the hereinafter described lands
shall be conditionally included in Northern Water. The Court, having considered said Motion
and being advised of the premises, finds as follows:
1. Pursuant to C.R.S. § 37-45-136(2), as amended, certain owners of lands Troy
Hefner and Judy Hefner ("Petitioners") have filed with the Board of Directors of the District
("Board") a Petition in writing requesting that such lands be included within the District
("Petition"), which Petition described the tracts of land owned by the Petitioners and is
acknowledged as conveyances of land are required to be acknowledged.
2. The Petitioners and the lands sought to be included are set forth in Exhibit 1
attached hereto and incorporated herein by reference.
3. The Secretary of the Board caused notice of tiling of the Petition ("Notice") to be
given and published in Weld County, Colorado, in which said lands are situated, which Notice
stated the filing of the Petition, the names of the Petitioners, descriptions of the lands to be
included, and the request of the Petitioners, and notified all persons interested to appear at the
office of the Board at the time stated in the Notice and to show cause in writing, if any, why the
Petition should not be granted.
4. The Board, at the time and place so mentioned, proceeded to hear the Petition.
C rttf►ed t4;t e a foil, trip c,:rrt.
Copy of,the origlrial in rrty c: ,..'..
3905900 Pages: 1 of 4
01/28/2013 11:28 At1 R Fee:$26.00
Steve Moreno, Clerk and Recorder, Weld County, CO
lI
,ITV KIIIIIINdA1A11141.1*.Wiliclifirriatitilliiii III it 1
Patect r J. ! 2 GPI r3
CATvimL
Cleric 1,1e. -- -77:477
A ._
PETITIONERS
Troy Hefner
Judy Heftier
DESCRIPTION
A tract of land situated in Section 23, Township 1 North,
Range 68 West of the 6th P.M., County of Weld, State of
Colorado described as the 0/2WY2SEV4SW1/4.
10 Acres
Exhibit I
3
3905900 Pages: 3 of 4
01/28/2013 11.28 RI R Fee:$26.00
Steve Moreno, Clerk and Recorder, Weld County, GO
■IgEh 10I,Pia tit Ctl' IION IN, II
WELD COUNTY BOARD OF HEALTH
ENGINEER DESIGNED SYSTEM REVIEW
— PROPERTY OWNER: Troy and Judy Hefner PERMIT NO.: SP -1100033 (New)
LEGAL DESCRIPTION: PT: SECTION: 23 TOWNSHIP: 1N RANGE: 68W
SUBDIVISION: LOT: BLOCK: FILING:
SITE ADDRESS: 4343 CR 6, Erie, CO
- FACILITY: Commercial, 8 workers at 20 GPD and 20 customers at 5 GPD for a total of 260 GPD
• ACRES: 10
- PERC RATE: 9.72 mpi SOIL: Suitable' WATER SUPPLY: Central Weld Water District
LIMITING ZONE: greater than 8 ft.
XXX ENGINEER DESIGN (3.5) EXPERIMENTAL DESIGN (3.14)
ENGINEER: Alpha Surveying Co — Cecil Crowe, P.E.
ADDRESS: P.O. Box 392, Fort Lupton, CO
ESTIMATED FLOW: 260 G.P.D. average daily flow, 390 G.P.D. maximum daily flow
PRIMARY TREATMENT: Standard tank CAPACITY: 1000 gallons
- DISPOSAL METHOD: Absorption Bed SIZE: 452 square feet
- STAFF COMMENTS: The system is adequately sized for the proposed load.
STAFF RECOMMENDATION: Approval
ENVIRONMENTAL PROTECTION SPECIALIST: Lauren Light
REVIEWED BY BOARD: March 22, 2011,.
f.
B.O.H. DECISION: APPROVED: °' DENIED: TABLED:
�:r
Chair.
Weld County Board of Health
WELD COUNTY DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT
1555 NORTH 17TH AVENUE
GREELEY, CO 80631
PHONE (970) 304-6415 FAX (970) 304-641.1
Permit #:
Owner:
Applicant:
Permit Type:
Parcel 4: tsi
Location: 4343 WCR 6 ERIE 23- 1-68
Legal Description: 24925-C E2W2SE4SW4 2
(.2581 D)
Installer:
SP -9900524 Sec,/Twn/Rng: 23 01 68
MILLER JERRY DEAN & CO .T EY ILEA
MILLER JERRY
RNEW C=Commercial. R=Residential + NEW, REPair. VauLT
3 1 68 EXC UPRR _RES
Description: HOUSE
Commercial: Y.
Residential:N
# of Persons: 3 Basement Plumbing: Y
of Bedrooms: 3 Bathrooms - Full: 2 3/41. 0 1/2: 1
Water Public.: N Water Source:
Water Private: Y Cistern: N Vv ell:
Well P emit #:
Status:
Applied: 10/11/1999
Issued: 10/13/1999
Finaled: )J(R 9/f 9 9
Acres: 10
Percolation Rate:9.7 Limiting Zone: 8 ft 0--i. in Description.
% Ground Slope: 0 Dir: Soil Suitable: (Y/N) Y
Engineer Design Required: (Y/N) N In 100 Year Flood Plain: (Y/N) N
Minimum Installation
Septic Tank: 1000 gallons
Actual Installation
Septic Tank:/ -x -et, gallons
Design Type: C,r'1 .
Absorption Trench: 522
or Absorption Bed: 711
square feet
square feet
Absorption Trench: a z _ square feet
Absorption Bed: square feet
Chambers
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 subiect system will operate in compliance with applicable state, county and local regulations adopted persuant
to Article TO, 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 not transferable. 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 was contingent upon the
final inspection of the completed system by the Weld County Department of Public Health and Environment,-.
x
Envirpinnerital Health Specialist Date
Foam S FINAL
DOCUMENT: STATEMENT OF EXISTING
DISKETTE: HPS2B
STATEMENT OF EXISTING SEPTIC SYSTEM
(Fill out in ink)
OWNER OF RECORD:
6 r~` f".);)
02-157
MAILING ADDRESS: //. 170 WC
SITE ADDRESS: `sYs7,7..J t/' 2 -
LEGAL DESCRIPTION: P s P2 -'E -r l..ySec
Subdivision:
Bedrooms
Use type
Bathrooms
Lot:
Water. Supply
Lot Size
PHONE: 0
TWNSP t % RNG
Block: Filing:
Acres
SYSTEM SIZE: Tank is constructed of.2cand has
e ial -s..
. � wcvv-
ABSORPTION BED:
J (,) a O
Ft. Total Date System installed
gals capacity
/Z2 4
You are required to draw a diagram of the system on the reverse side of this form and
indicate position, length, width, and distance from the dwel.inga
The undersigned property owner hereby certifies that the above described septic system
is in fact installed, as described, and exists at this t:me on the parcel of ground
identified by the above description, and further states that the system is in good
working order and to the best of his/her knowledge is not felling to function properly.
I further understand that any falsification or misrepresentation may result in
-revocation of any permit granted basedupon this information hereby submitted and in
legal action for prejury as provided by law
r ate
•
r r
Subscribed and sworn to before me this /(
by.
Orro
itrxess my hand and official seal.
'.5/"gwv1 /MY
¢ca to
Owner
day of
19
J
My commI sion expires 7f,--19/
61/
f ,44411(
Notary Public
Accela Automation. GetPerSet25O - 8150-S
Pave 1 of C
user IS3: MSWALN Adivi.r `auto.
L:e,a,_ Sur
Application Type: rt.. _._ El ., -?r-., : L,
Application; Gig86Dc14
Owner Name: C ,tv3"Ii E'
Owner Address; rp:. .;:r;gr,,•e
Address: .. .., .
Aglpiication Continents:
Application Status:
Parcel No.:
FfIQ Dctp:
Y7psoription of Work:
Application Spec ,TnFo.r
Applicatier. Spec Info. Table:
Application De£aii:
Contact Info:
t.rcensod Professionals Info.:
Jab Value:
Tote! Fee Assessed:
Total Fes Invoiced:
Balance:
Warkflo!o Statea:
.r..ptl(irtion Status:
klase. Information
Eng Design REeq'et:
FEE PAID:
Fi{Etary:
Final Pate:
Final Date Text;
YnS'.3Elec':
Issued Date:
Issued telt:
L ocation:
Lot Size:
Owner/Agent:
PE;FHl;T FEE:
Pert Date:
Perri! No:
Szelt .in/F rig3:
Sec/Tv.ioprogZi
S ec; Tw n/Ftrrg 3:
Signed Date:
Signed bate 7r.rt:
Status:
System Type:
Type:
Year:
SC
OG'
.7,334
:-i3 Sf j F14_ _
AC-S...Pr
OC
•
25
6.
G3
32. '1948
J11''
Sere ices[ Inst plistian
S Of !4edroen-:s: _
« cP Persars:
'Slyewer=.t Pio:n53ag:
8aihrn�m^
FP -NI Size SQFT: C 3f
Cortrt:ercial: ..
Description:
er eend Slope:
institution:
Other:
Percolation Dole: 3(:'
^aRleis.^..iai:
Sail SuitaLie (n/U}:
TTn+ Capacity Gal: so:
Trenr-.h:
Trek,03 Size SQFT:
Water Depth: fop
Water Supply:
=.:. Ali
SG,3P
Tar -k
Condition Name
state'.
Sgattn
Status Date
Apply Data
Action lay
.Actin:: fop
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-$6,250.00
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