HomeMy WebLinkAbout20174042.tiffCOLORADO DIVISION OF WATER RESOURCES
DEPARTMENT OF NATURAL RESOURCES
1313 SHERMAN ST., Ste 821, DENVER, CO 80203
Main: (303),866-3581 Fax (3031 866-2223 dWrcerrnitsonilne(tstete-co us
RESIDENTIAL Note: Also use this form to apply for livestock watering
Water Well Permit Application
Review form Instructions prior to completing form.
Hand completed forms must be completed in black or blue Ink or typed.
1. Applicant Information
Nom
Office Use Only
1' ECER1IEi)
rST '41
i..C::i
COLI,t
Form GWS-44 (7/2012)
REC1VED _
APR 182016
WATER RESOURCES
DIVISION
GREELEY, COLORADO
ti
2. Type Of Application (check applicable boxes)
r: onstruct new well
Replace existing well
❑ Use existing well
❑ Change or increase use
3. Refer To (if applicable)
Well pom9i
❑ Change source (aquifer)
O Reapplication (expired permit)
❑ Rooftop precip. collection
❑ Other
Wear Cou rl rasa *
6. Use Of Well (check applicable boxes)
See instructions to determine use(s) far which you may qualify
❑ A. Ordinary household use in one single-family dwelling
[no outside use)
B. Ordinary household use in 1 to 3 single-family dwellings:
Number of dwellings:
7 Home garden/lawn lrrSgation, not to exceed one acre:
V I area Irrigated sq ft, ID acre
L}omestic animal watering — (non-commercial)
❑ C. Livestock watering (on fa rmlranchfrangelpasture)
7. Well Data (proposed)
Maximum pumping rale Annual amount to he withdravm
gpm
acre-feet
Total depth
• feet I Aquifer
Designated Been De bumf ration I
Wdtnenla or I
4. Location
�u -A
sectits
Dislunea of well from section ILnes (section lbws a re t9pfmly _ not pee way thee}
Ft. from TN r'S Ft. from0E CW
Yw faplaeerrrom , olle only - dL• nee and tiiradlnn cram old well to now twit
feet Direction
Well Walks addles (Maude Chy, Shia, Zip) f Check If well address le samosas In Ilerrr 1.
f Proposed Well (Important! See Instruction,
I POLO ,+a or me t,,..f......
Tw rise p Nor 5 ILange K ar W PrFrapel AAoridian
T
Optima!: OPS well location Intomatron In tITM format. OPS unit soringeere as follows:
Forman must be Lan
zone 5z n(l— Zone 13
Clods must do Motors
Datum men be NADSS
Unit tram be net to hue north
Was GPS unit checksd for above? ❑ YES
8. Parcel On Which Well Will Be Located
You must.attach a current deed for the subject
A. You must check and complete one of the following
O Subdivision: Name
Eastina:
Northing:
Remember to set Datum to NADS3
8. Water Supplier
Is this parcel within boundaries of a water service area?CI YEBII
If yes, provide name of supplier:
9. Type Of Sewage System
4eptic tank / absorption leach field
❑ Central system: District name:
❑ Vault: Location sewage to be hauled to:
❑ Other (explain)
10. Proposed Well Driller License #(optional):
! 1. Sign or Enter Name of App 'lungs} or Authorized Agent
The making of false statements herein constitutes perjury in the second
degree, whim is punishable as a class 1 misdemeanor pursuant to G.R.S.
24-4-104 (18)(a). I have read the statements herein, knowthe contents
thereof and state that they are true to my knowledge.
Signor wrier name(e) of person(s) subbeMd n�pplical Wn
Dale (mn dd+riri)
'-I - a`8-) e
Irelg� prh l narrra and title
- �+tZq." —\ to. ON.c dR.P
Lot R1ock Filing/Unit
❑ County exemption (attach copy of county approval & survey)
Name/# Lot #
❑ Parcel less than 35 acres, not in a subdivision attach a deed with metes
& bounds description recorded prior to June 1, 1972, and current deed
Mining claim (attach copy of deed or survey) Name/#:
Square 40 acre parcel as described in Item 4
Parcel of 35 or more acres (each metes & bou,de description orsurvey)
Other. (attach metes & bounds descnption or survey)
O
B. ftoFOaoyinpawl C. Are ulhsewer ofthisparcel?
§IYEs)( NO
D. WIIhIsbaths onlywallonthispercw-17 stn NO (d no—MelofferImes) -
E. State Parcel trill (op6orlalp: FTi 5 [ 17 5
Office Use Only
USGS nap name -
DWR map no.
Surface elev.
+ Receipt area only +
(Lae_ IrJ.2� 2.412.(03 i i .J` .-tti
AQUAMAP
WE ti
wire,,
`NCB ,
TOPO Y
hN't'C4i'
tckike_tir dr; Lied,
Ali
600
.2(
'irorir.lo,cfir}rt + 'f
Date: O22/2016 1 t:13:4b AM
Transaction Total: S100.00
CHECK§9te)5S t100.00
24 2c4 -Ce*r- 4Oae.
1.0112_('4 OE
DIV . WD / M__� MD
DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT
1555 N. 17th Avenue
Greeley, CO 80631
www.weldhealth.org
Px„eer •ream!' Frm,c%
Health Administration Public Health & Clinical Environmental Health Communication, Emergency Preparedness
Vital Records Services Services Education & Planning & Response
Tele: 970 304 6410 Tele: 970 304 6420 Tele: 970 304 6415 Tele: 970 304 6470 Tele: 970 3345420
Fax: 970 304.6412 Fax'' 970 304 6416 Fax: 970 304 6411 Fax: 970 304 6452 Fax: 970.304 6459
Out vision' Together with the ccmmunllies we serve, we are working la make Weld County the healthiest place to live, learn, work and play.
Septic Permit - Final
Application Number:SP-1600242
Owner Name:KUTCHER DENNIE L & CLAYTON HOMES
Site Address: 31608 CR 74
App Type: HealthlResidentiallNew OWTS\Septic
TONY COLLINS
CLAYTON HOMES
3455 W SERVICE RD
EVANS, CO 80620
Parcel #: 079905100016-R2591303
Legal Desc: PT W2NE4 5-6-63 LOT B REC EXEMPT RE -3553 (.57R)
Work Description: MODULAR
EHS SEPTIC GENERAL:
Associated Disaster Permit No
Number of Bedrooms 3
Number of Persons 2
Parcel Acres 68.89
Private Water Supply Permit Reference 301180
Public Water Supply No
Repair Reason Type New
Waive Fees No
EHS SEPTIC ACTUAL (FINAL):
Septic Tank Size, gallons 1500
Absorption Trench, sqft 480
Chamber Model Quick4 Standard or High Capacity
Number of Chambers Installed 40
Design Type Chambers -Trench
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 25-10-112(1)(b), C.R.S.
This perrnit is non -transferable and non-refundable. 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.
Finaled
Alex Clemments November 17, 2016
Application Status:
Finaled
Applied Date:
08/23/2016
Issued Date:
08/30/2016
Finaled Date :
11/17/2016
Environmental Health Specialist Date
Page 1 of 1
INPSECTION
PORTS
N
25'
25'
50'
Other Ivan it* drelances to setback 04]ects irtdicaled on the design documgnls, no Oilier
ohleal5 requiring setbacks horn the prpposetl OWES as indicated In Table 34-l-1 oT
Cttapler 3C of the Weld County Code, have beon 9oCatad Or observed dtering
our pr irs nary investigation, reconnaissance or derailed soil invesligation
40 STANDARD QUICK 4 INFILTRATORS
(4 ROWS WIDE BY 10 LONG)
TEST
PIT
D -BOX
SEPTIC
TANK
ANHGNflO9 Aiinc1O id
WE ARE UNAWARE OF ANY RIGHT OF WAY SETBACKS ON THE PARCEL
THAT COULD AFFECT THE PLACEMENT OF THE PROPOSED OWT5
BORING LOCATION PLAN
PROPOSED SEPTIC SYSTEM
31680 WELD COUNTY ROAD 74
GALETON, COLORADO
FOR DENNIE KUTCHER
Northern
400ANColorado
Ge teoh
295628th Street, Unit 21
Greeley. Colorado 80634
Phone: (974) 5069244
hex: {970) 506-9242
Plgsct No,
116-11
1"a50'
Ceisc
8-5-16
PingdMi
DML
Fors No. 2
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