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Permit #
Permit Type:
Scanning Cover Sheet
for
Septic Permits
619700467
Health/ EHS History / EHS Conversion History
Sim Street Address 2091 CR 10
Sites City, State, Zip
Sec/Town/Range: 09 -01N -68W
Parcel (12 disks)
Owner Full Name:
Chimer Address:
:
Contact Name:
Contact Address:
1 ii70900007'9-80651701
HICKS MELVIN
2091 WCR 10
ERIE,CO 80516
Application Status; Firm/ed
Application Date: 03/11/1996
Owner Phone #: 303 6652251
Contact Phon
Information above has been Verified in MM e/a b ern .10 se noted below
x
Processed by:
Report ID: EHS00024v003
Print D :rime: 5/5/2 2:36:07PM
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May 05, 2009
Date
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Page 1 of 1
'5%IT/ MI5
WELD COUNTY HEALTH EPARTMENT
i
15th Street and 17th Avenue
P. O. Box 1227
Greeley, Colorado
1OOL4Lq
No.
Application for Permit to Install, Construct, Alter or Repair Individual Sewage Disposal System.
Owner or Spoor M_dress
121,ACS
Address of Sites
Mailing Address
General Information
1. Living Units
2. No. of Bedrooms
3. No. of Baths
4. Basement Drain -I _ -
5. Automatic Dishwasher
6. Garbage Disposal
74 Automatic Laundry j
8. Size of Lot
9. Type of Soil
10. Percolation Teat
lip Water Supply''.
12. Lot Grade
M .
13. Water Table Depth � �_
14 Other
Phone
Sral
E'er-tU coa gp
bin S -, A5"�,
drec)
r
Septic Tank
1. Liquid Capacity govi, Gallons
2. Dimensions !►'' L I
8. Material Pr
4. Type Inlet
Type Outlet
n
a
C
Secondary reatrent
Field A 1319 Bed
1. No. of distribution lies _3
2. Trench: Widt
3. Type Filler Material
4. Depth of Filler er Material 1
5. Gravel Size
6. Type The
7. Depth of Cover
8. Other
Length ifinl'
The Permit is to remain in full force and effect for six (6) months from date, until revoked for non-compliance.
Thin system will be constructed in accordance with the above specifications and regulations governing non -
municipal sewage disposal systems, in accordance with Regulation No. 1 of the Weld County Health De-
par'taient.
Date: Applicant:
The plans and specifications as shown are approved, pending payment o
Sanitarian:
Date:
The above system inspected and found to comply with the plan and description,
Installed by
PERMiT FEE $
Received by
Sanitarian:
Please use reverse side for Plot Plan or use separate sheet of paper.
it fee.
Date
•
a
•
Mel
■ 1
r
HSF 1 o IP
rT
OWNER HICKS/ MELVIN
6191 DO
INDIVIDUAL SEWAGE DI SF'UE AL SYSTEM PERMIT NO. 0--700467
r
WELD COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH SERVICES
1$17 16TH AVENUE COURT, GtEELEY , CO 80631
353n0635 E T .2i 2 5
ADDRESS OE PROPOSED SYSTEM 2091 WCR 10
ERIE CO 005:16
LEGAL DESCRIPTION OF SITE: S2 SW4 SEC 9 TIC P 1 RHO 68
SUBDIVISION: LOT 0 BLOCK 0 FILING
USE TYPE: RESIDENTIAL ORIG OWN MC 'GEE -LOAN #190-93
SERVICES: PERSONS 6 BATHROOMS 1.50 I..OT SIZE 6.00 ACRES
BEDROOM; 2 BASEMENT PLUMBING YES WATER SUPPLY 1 'WELL
NEW PERMIT
APPLICATION F; E E $0.00
RECD BY X STAFF
DATE 07/01/70
ADDRESS 2091 WCR 10 PH (30 a) 665-2251
ERIE CO 80516
STONED BY DONALD MCGEE
DATE 07/01/70
PERCOLATION RATE iD. D MIN PER INCH LIMITING ZONE 0 FEET
SOIL TYPE SUITABLE PERCENT GROUND SLOPE 0% DIRECTION
REQUIRES ENGINEER DESIGN NO IN 1000 YEAR FLOOD ELA/ N ZONE NO
FROM THE APPLICATION INFORMATION SUPPLIED AND THE ON -SITE ITE SOIL,. PERCOLATION DATA
THE FOLLOWING MINIMUM INSTALLATION SPECIFICATIONS ARE SECIUIRED R
SEPTIC TANK 1000 GALLONS, ABSORPTION :I:ON TRENCH 570 Saw FT.
OR
ADSORPTION RED SO. rr.
IN ADDITION 5 THIS PERMIT IS SUBJECT TO THE FOLLOWING ADDITIONAL TERMS AND
CONDITIONS:
•—
-•^“� •••r rtti T...rs...a jai Sal a a..i a■s irOdflO � Yaagal �a.fl nii�i
THIS PERMIT IS GRANTED TEMPORARILY TO ALLOW CONSTRUCTION TO COMMENCE. THIS 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 CONSTITU'T'E ASSUMPTION BY THE
DEPARTMENT OR ITS EMPLOYEES OF LIABILITY FOR THE FAILURE OR INADEQUACY OI_. THE
SEWAGE DISPOSAL SYSTEM.
X STAFF 07/00/70
ENVIRONMENTAL SPECIALIST DATE
THIS PERMIT IS NOT TRANSFERABLE AND SHALL BECOME RE VOID IF SYSTEM CONSTRUCTION HAS
NOT COMMENCED WITHIN ONE YEAR OF : TB ISSUANCE. BEFORE ISSUING FINAL APPROVAL or
THIS PERMIT THE WELD COUNTY HEALTH DEPARTMENT RESERVES THE RIGHT TO IMPOSE ADDI-
TIONAL TERMS AND CONDITIONS REQUIRED QUIREI 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 DEF'AR IMENT .
SYSTEM INSTALLER UNKNOWN
SYSTEM ENGINEER
TYPE OF SYSTEM INSTALLED TANK
FINAL INSPECTION DATE 08/11/70
APPROVAL. X STAFF
ENVIRONMENTAL SPEC .I+i x'iL ,G Sir'
THE ISSUANCE OF THIS PERMIT DOES NOT IMPLY COMPLIANCE WITH OTHER STATEN 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 PERSUAMT TO ARTICLE 101 TITLE 25, CIS 1973, AS AMENDED ,t
EXCEPT FOR THE PURPOSE OF ESTABLISHING FINAL APPROVAL OF AN INSTALLED SYSTEM FOR
ISSUANCE OF A LOCAL OCCUPANCY P'ERMI'T PURSUANT TO CRS 19R 25-10-111 (2) .
ORIGINAL -APPLICANT; COIµ'Y-WCHD WCf.ID-"EM MAY;, 1904
FIELD: Bed
• WILD Min DEPARMENT IdhittaNTAL PROTECTION SERVICES,
e 1517 16th Avenue Court
Gamey, Colorado N631
(303) 3 a0633
OWNER OP RECORD:
S
LOIN FEE $10.00
SCE t:
41:
ISDS
REPAIR9;
STATEMENT OF EXISTING FOR SEPTIC SYSTEM
(PLEASE FILL OUT IN BLACK Ili€ ONLY)
ONE :_ z n
ILING ADDRESS: , . 0
$ITE ADDRESS i
iEliefe0
City
City
CO
Stets
LEGAL DESCRIPTION: 7:5 z r:5'/EE almaTOWNSHIP: N E 68 If
E /OA of Lei za A Sart eivretA Elet 400,,Crit cas
SUBDIVISION: : BLOCK: FILING:
OF PEOPLE:ogieBEDROOMS: BA R S : I Pr a WATER SUPPLY:
I COMMERCIAL BASEMENTPLUMBING:
4
R LOT SIZE: acres
SYSTEM SIZE: Tank is constructed of CO+4K`lnTE and has / 000 gallons capacity
(material)
— — square feet. DATE SYnak3 INSTALLED: /9 7y'e...
You are required to draw a diagram of the system on the reverse side of this for= in
Maack ink oar and indicate location, on, length, width, and distance fops the dwelling.
The undersigned property owner hereby certifiers that the above described septic system
is in fact installed, as described, and exists at this time an a parcel of ground
identified by the above legaldescription and further states that the system is in good
working order and to the best of his /her knowledge is not failing to function prciperly.
I further rdei std that any falsification or misrepreseathtic may result in revocation
of any permit granted based upon this info rmati .hereby submitted and in legal action
for . ! rdurr as provided by law.
Owner
Subscribed and sworn before me this
by
Witness my band and official seal.
Date
STATMENT OF EXISTING REVIEWED BY:
expires: a
ota Pubi
a
Environmental Protection Specialist sat
•
Btr -ct F oniartj
NNW Oath arid Return Top Porton woe Your Pernent
6 30 s m a 4 30 p.m, Monday Fnday Bang Inquiries ((303P 530-420D
11414 vaviW. i tixr_d lef cog lor tisequeiltiy asked tI tilts Inalsrr ,
L T Ltri BILL
2091 commie ROAD 10
SEA PROVIDED FROM i
PRE Vi READttiGi
ADDITIONAL INFORMATION
up V 110, a FREE Outdoor
mite
kw Ranores C-'va A ylou weal
nett' io have 411 y a ratauni S Can
OllaY to tipipowatmerit a
24 Cr go wine Ior
Cornuantsbonirantor tier
titre Space rk, Irrnattd
munalafillrilL•.. 4. P*44. frt P-C1f4
ReSource
21 CONSIRIATMMPI
I
AC.02• ANT NUMMEF
,DAYS 1111s ttILLGhiG
DESCRIPTION OF SERVICES
PREVIOUS BALANCE
PAN' 071172011
ADJUSTMENTS
WATER BASK FEE
WATER USAGE'.
ACTIVATION FEE
SksLUTQFF onvagg
miscatarous
r hank You
Atcari Balance
17'9 30
246 :504
.a SCR
. 11
402.71
361 .87
TOTAL AMOUNT DUE
1,57
`Irk J.I SJ Rat': helm; 1k, N" thousand gallons,
R!\Ii)I'Nii AI
hit sj
Neu Wow latfital
Neu It$* S
(ha tS0,0110 $121
nwORT ANT INFORMATION
MATT ION
F F1 IL 'i'T ^ I 1 M 4. 4 AP& R+. I k1
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.47 Al ] I $:o, p
KiticIi1MI I i M N4;
Iu.I Alt I
34)3
WIC
45000
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LEFT NAND WATER ITT mare M P 0 sot 2 o. tosci, co 80 54402 tO Orkat Ainttn We Itindi a0.
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