HomeMy WebLinkAbout20173310.tiffWATER SUPPLY: PUBLIC
PRIVATE
PARCEL#
WELD COUNTY DEPARTMENT OF PUBLIC SE #
HEALTH AND ENVIRONMENT
1555 N. 17TH AVENUE REPAIR#
GREELEY, COLORADO 80631 LOAN #
PHONE: (970) 304-6415 ISDS #
FAX: (970) 304-6411
STA'T'EMENT OF EXISTING FOR SEPTIC SYSTEM
THIS DOCUMENT'S NOT A SEPTIC PERMIT
1O9t ()C ( L! -
PROPERTY OWNER,Pc \ \ pro PHONE NO. (3 a) cgI g- '39 3
MAILING ADDRESS .. 1 g 1 o) �. C �� i e CO " 0 g
SHE/LOCATION ADDRESS SC,.
City State Zip i
LEGAL DESCRIPTION: PT 1/11- SECTION__,_ TOWNSHIP 1 nyr 11 RANGE 6
SUBDIVISION LOT BLOCK FILING
LOT SIZE CRE.�-
City
State Zip
COMMERCIAL: RESIDENTIAL:
RESIDENTIAL:�,Q
DESCRIPTION OF B G AND YEAR BUILT (ex. Ouse, mobile/modular home, shop, office):
NUMBER OF PERSONS NUMBER OF BEDROOMS '
BATHROOMS FULL_L_ 314_j_ 1/2 t €1f
WATER DIS CT NAME L a�4
WELL _ u O CISTERN S Permit#
Circle which applies- ...TEJLLJ
SYSTEM SIZE AND STRUCTION:
SEPTIC TANK: Se tic tank material is constructed of Conic= ,d has I NCO gallons c c'ty
FIELD: Trench 3 square feet or Bed square feet "Y AR INSTALLED rt (Ol
Provide a drawing indicating dimensions and location of the existing septic system, including distances from property
lines, easements, dwelling, other lot improvements, water line, water well, surface water features such as ponds,
irrigation ditches, etc.
TIER 2 TIER 3
The undersigned property owner hereby certifies that the above described septic system is in fact installed, as
described, and exists at this time on the parcel identified by the above legal description.
I further understand that any falsification or misrepresentation may result in invalid results in determining compliance
with current regulations based upon this information hereby submitted and in legal action for perjury as provided by
law.
DA E O f R SIGNATURE
Subscribed and sworn to before me this L5 day of
by ?c..1 '---)O1r\aYN::)�G.
Witness my hand and official seal,
•15
DATE
STATE
\-"). ANNE SANDFORD
NOTARY PUBLIC
STATE OF COLORADO
NOTARY ID 20084017845
6s�ava-c„ae-to
5 .1m.1 -O
y ciission expires:
NOTARY PUBLIC
, 20 ' �-
DATE
OFFICE TECHNICIAN
6/15/2017
Xpress Bill Pay: Bills
Left Hand Water District
Left Hand Water District
PO Box 210
Niwot, CO 80544
303-530-4200
lhwd c ielt'handwater.arg
Of ce hours are Monday - Friday 8:30am -
4:30pm
Remove Account
Have your bill paid automatically each month with Xpress Sill Pay's hassle -free Auto Pay feature.
Billing Address
WILDER DALLAROSE . PATTI
2181 COUNTY ROAD 10
ERIE. CO 80516-8602
Disscrlp,:on Bead Date
US 3/24/2017
Previous Payment Date
Previous Payment Amount
Prey Pearling
928
Service Address
WILDER DALLAROSA . PATTI
2181 COUNTY ROAD 10
ERIE CO 80516
Present Reading Total Usage
933
5,000
3/2/2017
$72.2
Account Information
Account
Number:
Bill Type:
Due Date:
Billing Period End;
4343.03
Utility
4/21/2017
3/31/2017
Total Charges
WATER BASIC FEE
WATER USAGE
$26.1:
$18.05
Statement Charges
$4426
Payment on 4/4/2017
-$4416
Statement Total
$0.00
The information displayed here la provided by Left Hand Water District. It there is a discrepancy. please contact Left Hand Water District. Please note that
model bill is only displaying payments made on or after 04/01/2017. Payments made directly to Left Hand Water may or may not be displayed here_
https://www.xpressbilipay.com/customer/#/bills/2191759309044
1/1
Company Name: J U C I1 U ? / 1lfc
Customer Name: �1 Yri Q Ito r QS Q
Address of Pumping o2 is, O
Phone amber: '%2
Pumping Date: (P - '7 - / '1
1. Tank Size: /o'{.cD Gallons Pumped:
2_ Lift Station Yes No Ifs: fiinctiOning Yes No�
_ Excessive water mining back into tank li um field? Yes No
If yes, estimate in gallop:
4_ Liquid level in tank over inlet line? Yes No
5_ Tank Constuc n (3 w.rk one)
Concrete iv"- Metal Brick Plas6c or Fiberglass
Cesspool orSeepg Pit Other
6_ Tank Construction Observed:
One CoiripaTIMCSIt Two Compartment v"--
7_ Inlet/outlet tees and/or baffles in good condition? Yes v„,'"N
S_ Filter on outlet cleaned and inspected (if applicable)? Yes : No
9. Access to clean -out lids within 8 inches of grade?
Inlet Yes No Outlet: Yes —No
10_ 20 ml_ plastic x enlaced and sealed over tank lid (flood pbnin only)? Yes No +�
11. Tank/lid structurally some and water tight? YesV--' No
12. Obvious c-ackstleaks observed? Yes No
If yes, explain area:
13. Other conditions noted which may affect proper functioning of system?
EAK _4AcAELA _6 kit- #it
14 Reason for Service: CC..II
Maintenance Real Estate Sale mergency/Backup
Other
PLEASE DRAW A DETAILED MAP TO YOUR PROPERTY with directions from the
nearest two county roads. If the property is in a security or gated area, please indicate the code or
other instructions for entry on the map.
N
N
21 t co" L�;e, Co qo c
AS°
MARKER
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m. 4
zz
1'7Cg A c
PLANTER r�
21926
X x _
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SPICKET-)
331.84'
ONE Q NTes`'
WELD COUNTY ROAD 10
PROPERTY DETAIL
t"=30'
3B_7' #2181
1 STORY b
DWELLING to
58.6' _
BILCO
DOOR
WOOD
SHED
GRAVEL
DRIVE
• Label all roads
• Label subject property with address
S Indicate nearby landmarks, such as businesses, structures, natural features
25.61'
29.61'
7
7 d
x l:, _ sc Contact t. to •'e
tnatiori
BUEZil)eSS
.u2v�a.__.'—l•��,�-
Customer's
Order No. Date s ` ).-% 1 `` 20
Sold to , \ 1 `.-� l ;rirC? .9
Address j J c ` \----- 1 { `
�.t'
i.., 4th �`
Phone ._ !;� j� 4,
MDSE SOLO
MUSE. RETD
RECD- ON
CASH
CHARGE
CASH
CREDIT
ACCT. - NOTE
F/IISC'L
PAID OUT
QUAN.
!000Ci
NUMBER
. , P
Cat
ARTTCLES
PRICE
AMOUNT
ter,"'.c;
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TOTAL
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Ail claims and returned goods MUST be accompanied by this bill.
r: m t
s _ \i lw.
Salesman / `' i . ) Received By
CSA-210.2
PRINTED IN U.S.A.,
IPRINTED
5OY INK!
Ogrolcy.
ONSITE WASTEWATER TREATMENT
SYSTEM (OWTS) EVALUATION
APPLICATION
ISDS
DATE RECVD:
RECEIVED BY:
FEE:
NO:
PARCEL NO.: l t G r1 0 O0OO'1 � (12 DIGIT NUMBER)
LEGAL DESCRIPTION: SECTION I TOWNSHIP 1-"' RANGE C J6) ACRES I O
SUBDIVISION LOT BLOCK FILING
THIS INFORMATION CAN BE OBTAINED FROM THE WELD COUNTY WEBSITE:
11[ co we ci. o. usimansj roDertV1r1'tornIalIor.-
SITE ADDRESS: g I to j CO c {+� .1 0 C_ tO z` C-(�
SEPTIC PERMIT NO.:
REASON FOR OWTS EVALUATION (recorded exemption, change of use, adding bedrooms): (\t) pe,i I'Y11 .-- .fc
RECORDED EXEMPTION NO. (if applicable):
PROPERTY \ �`
MAILING ADDRESS: +a I Co t' IA -1,/ R a 1 �1 CITY E I ..1F' STATE C C ZIP
HOME PHONE: I t WORK PHONE L� ( e7(D FAX ( )
EMAIL ADDRESS:• I la e--- 66-c 1 L -o F'V1
(IF APPLICANT IS NOT THE OWNER, ATTACH OWNER AUTHORIZATION FORM)
APPLICANT NAME: PC,
MAILING ADDRESS: t C O f.) fV-\j R-6 (0, CITY {mot e STATE CO ZIP qo S( (--s
HOME PHONE: (3051_ I3. -I 3`'13 1 WORK PEIO`rE (303 ) (0 5._C6 S`f FAX ( )
EMAIL ADDRESS: p o�Tl s t ci 1 1&2{' ` Cr-C- k �eG tyc� Co ir►\
G 11
OWNER:
DESCRIPTION OF STRUCT E
- ! SAO?
CURRENT USE (House, Modular_ Shop): - 5 i c e ce' ( _ I -7�tar) 'A97
NUMBER OF PERSONS 2-- NUMBER OF BEDROOMS /- BASEMENT PLUMBING YES O`,
BATHROOMS: FULL ( 3 [ v
PUBLIC WATER SUPPLY/ NO WATER DISTRICT NAME if
PRIVATE WATER SUPPLY YES 10 1 WELL /CISTERN PERMIT if
PROPOSED CHANGES (]louse, Modular, Shop): J k(; p i r'eA i cLer.tee
NUMBER OF PERSONS 2-- NUMBER OF BEDROOMS BASEMENT PLUMBING YES
i/z
BATHROOMS: FULL I /a
PROPOSED TOTAL (House, Modular, Shop): i�`2`91 .f�f . '�� ko
NUMBER OF PERSONS ~Z— NUMBER OF BEDROOMS 7 — BASEMENT PLUMBING YES / VO'
BATHROOMS: FULL +1
37
I HEREBY CERTIFY THE ABOVE
SIGNATURE OF APPLICANT
1
/
RMATION IS CORRECT AND ACCURATE TO THE BEST OF MY IO OWL
DATE ( 1,5 _
NEITHER THE COUNTY OF WELD OR ANY OF ITS AGENTS OR EMPLOYEES UNDERTAKE OR ASSUME ANY LIABILITY TO THE OWNER
OF THE ABOVE PROPERTY, TO ANY PURCHASER OF THE ABOVE PROPERTY OR TO ANY LENDING AGENCY MAKING A LOAN ON THE
ABOVE PROPERTY OR IN THE REPORT.
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