HomeMy WebLinkAbout20172002.tiffScanning Cover Sheet
for
Septic Permits
Permit #
Permit Type:
Situs Street Address
Situs City, State, Zip
619700554
Health / EKS History / EHS Conversion History
15741 CR5
Sec/Town/Range: 17 -03N -68W
Parcel # (12 digits)
120717000035-R0157391
Owner Full Name: HOPKINS ARDON
Owner Address: 6x.349
MEAD,CO 80542
Contact Name:
Contact Address:
Application Status: Finaled
Application Date: 03/11/1996
Owner Phone #: 000 0000000
Contact Phone#
information above has been Verified in Accela bV employee noted below
x
Pro ssed by:
April 30, 2009
Date
Report ID: EHS00024v003
Print Date -Time: 4/30/2009 1:54:06PM
Page oft
a
WELD COUNTY HEALTH DEPARTMENT
15th Street and 17th Avenue
P. 0. Boa 1227
Greeley, Colorado
Application for Permit to Install, Construct, Alter or Repair Individual Sewage Disposal System.
Owner or Sponsor
Aft:filerneiS ..,-41,91.0604/
Address of Site Ir Lieci inn
Mailing Address _..�
General Information
1. Living Units
2. No. of Bedrooms
3. No. of Baths 4. Basement Drain - 5. Automatic Dishwasher t
6. Garbage Disposal t
7. Automatic La idry
8. Size of Lot., '4
tver
9. Type of Soil
10. Percolation Test
11. Water Supply !i
12. Lot Grade
13. Water Table Depth
14. Other
Address
22X .
I
1 fris e. S
No.
Phone
Septi n
+e+n+u
1. Liquid Capacity Gallons
2. Dimensions W L D
3. Material
4. Type Inlet
Type Outlet
Secondary Treatment
Field 9 _ Bed 'O6 —Alf
1. No. of distribution lines
2. Trench: Width _
3, Type Filler Material
4. Depth of Filler Material
5. Gravel Size
6. Type Tile — —
7. Depth of Cover
8. Other
Length
The Permit is to remain in full force and effect for six (6) months from date, until revoked for non-compliance.
This 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-
partment.
/0-‘.:7o
Hate:
The plans and specifications as
The above system ins
Installed by
Applicant:
shown are approved, pending paymenpermit fee.
Sanitarian: •Date: Clef 1 �I q 7o .
ted and found to comply with the plan and description.
Sanitarian:
PERMIT FEE $
Received by
Please use reverse side for Plot Plan or use separate sheet of paper.
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Date
P.
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