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Home My WebLink About20161477.tiff OWei CENTRAL WELD COUNTY WATER DISTRICT November 16. 2015 Sheri Lockman 36509 Counts Rd 41 Eaton CO 80615 RE: Additional Water Sen ice for ATimmer Dear Ms. Lockman: -Fhis letter is in response to a request for water service to serve the following property described as foilows: Lob B of Rec Exempt RE-3428 being a part of the SW !-,of the SW b5 of Section 28. Township 2 North. Range 67 West of the 6th P.M., Weld County. Colorado Parcel 1;131 I 283001)056 Water service is presently available to the above described property by tap number 948 located at Weld County Road I7 bens een Weld County Roads 16& 18. Additional water sen ice can be made available to this property with a new tap purchase. provided all requirements of Central Weld Counts Water District, Northern Colorado Water Conservancy District and the Bureau are satisfied. Please note that it is your responsibility to contact Northern Colorado Water Conservancy District at 8/)0-369-7246 for petitioning confirmation into the Northern Colorado fluter Conservancy District Central Weld cannot issue a tap until all requirements are satisfied This is in accordance with the Rules and Regulations of Northern Colorado Water Conservancy District. Central Weld Counts Water District is aware of the planned RV Storage. If there are fire flow requirements. a feasibility study WILL need to be completed with our otlice as their current tap yyill not provide fire flow. Central Weld Counts Water District requires that contracts be consummated within one I I)year from the date of this letter or this letter shall become null and void unless extended in writing hs the District. Please contact the Central Weld office for further information about water service. Due to the rapid cost increase of raw water. existing tap fees may not apply fir water service to this propels. The District will not notify, by separate letter. any prospective landowners or land purchasers of tap fee or line extension cost increases. The cost of a tap fee and/or improvements will have to be paid in advance to the District by the prospective customer in accordance with District polio. It is your responsibility to confirm w ith your local Fire Protection Authority if tire flow water capacity is required for your project. If you have any questions regarding the abuse. please contact this office. Sincerely. CENTRAL WELD COUNTY WATER DISTRICT / -'` — Sthn Linker. District Manager SL/jr 2235 2i° Avenue • Greeley, Colorado 80631 • Phone (970)352-1284 • Fax (970) 353-5865 Stan Linker. District Manager Diana Aungst Subject FW: Septic dump From: sherilockman@what-wire.com [mailto:sherilockman@what-wire.com] Sent: Friday, February 19, 2016 2:36 PM To: Diana Aungst<daungst@co.weld.co.us> Subject: Re: Septic dump It is a future RV dump station. Sheri daungst@co.weld.co.us wrote: From: Diana Aungst<daungst@co.weld.co.us> To: "sherilockman@what-wire.com" <sherilockman@what-wire.com> Subject: Septic dump Date: Fri, 19 Feb 2016 21:33:03 +0000 Sheri: One last point of clarification — in the application it states "Septic Dump" is this an RV dump station or something different? Thanks, Diana Aungst, A1CP, CFM Planner 11 Weld County Department of Planning Services 1555 N. 17th Avenue - Greeley, Colorado 80631 970-353-6100 ext. 3524 Fax: (970) 304-6498 daungsta weldgov.corn www.weldgov.com MP t T _ ®®O Confidentiality Notice:This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged,confidential or otherwise protected from disclosure.If you have received this communication in error,please immediately notify sender by return e-mail and destroy the communication.Any disclosure,copying,distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited. 1 v. WELD COUNTY DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT • a 1555 NORTH 17TH AVENUE GREELEY, COLORADO 80631 PHONE (970) 304-6415 FAX (970) 304-6411 STATEMENT OF EXISTING SEPTIC PERMIT Permit #: SE-0200086 Sec/Twn/Rng: 28 02 67 PERMIT Owner: WIMMER WILLIAM & HANS Applied: 09/12/2002 Applicant: WIMMER WILLIAM & HANS Parcel N: 1311-28-0-00-032 Location: 7124 CR 17 • Legal Desc: 20416 PT SW4SW4 28 2 67 BEG SW COR OF SE C THENCE N1312.44' N Description: HOUSE Commercial: N Residential: Y Acres: 28.38 N of Persons: 1 Basement Plumbing: N N of Bedrooms: Bathrooms - (Full): 1 (3141: 1 (1/2): 0 Water Public: Y Water Source: CWCWD Water Private: N Cistern: N Well: N Well Permit Number: i Septic Tank: 900 Tank Material:(CQIiCREJE- Absorption Trench sq. ft. Absorption Bed: 2700 sq. ft. Year Installed: 1955 NOTICE The property owner'agent has certified by Notary Seal that the above described septic system is in fact installed as described,and exists at this time on the parcel identified above by the parcel number and/or legai description. and further states that the system IS/ IS NOT in good working order and to the best of his/her knowledge IS/ IS NOT failing to function properly. The property owner agent runner understands that an falsification or misrepresentation may result in the revocation of any permit granted based upon this information hereby submitted and in legal action for perjury as provided by law. The Statement of Existing Record relies on information the property owner or his/her representative provides, under oath, indicating current status of the system and representing to the best of hisher knowledge that the system IS/ IS NOT failing to function properly. Issuance of the Statement of Existing Permit for any system does not constitute assumption that the site was evaluated or inspected during any phase of construction by this Department to meet regulations. X le Environmental Health Specialist Date Form: S_EXIST WELD COUNTY DEPARTMENT OF PUBLIC SE # c f9 OQQg(,) 1IJ HEALTH AND ENVIRONMENT ORG PERMIT# '�� \ 1555 N. 17'" AVENUE REPAIR # I GREELEY, COLORADO 80631 LOAN # lung FAX:PHO (970) 304-6411E: 04-6416415 ISDS # Dak } COLORADO STATEMENT OF EXISTING FOR SEPTIC SYSTEM (PLEASE FILL OUT IN BLACK INK ONLY) PARCELS.* 131i -243 -0 - 00 -9 Z- PROPERTY OWNER kin LLJAHVA44JA4S Wail MCA PHONE NO. 1303 1 833 - 5-eyso NIAILLNG ADDRESS 712 + JA/Q1-3 17 Fotr I_vP;o4 CO y3 O &2-1 Cin State Zip DESCRIPTION OF BLTLDI\'G lex.]house. mobile/modular home, shop. office) 4OUSSE SITE/LOCATION ADDRESS -/1 a ¢- woe 17 F-7-Lvf7 J Co 001e2-1 f City State Zip /,� LEGAL DESCRIPTION PT5WK+ PT$$U/¢ SECTION 313_ TOWNSHIP 2.N RANGE W7kV/ SUBDIVISION R E 705 LOT BLOCK FILING CENCUS TRACT LOTSIZE,_ACRES ZS,f% COMMERCIAL YES :CD RESIDENTIAL ES NO NUMBER OF P KRSONS / 1 BASEMENT PLUMBING yESGD BEDROOMS /2- BATHROOMS FULL / 3/4I_ 1/2 0 Co. WATER SUPPLY PUBLIC YES NO UTILITY NAME 6 ikL jA,)gLD kV/Ma J7/57-: PRIVATE )(Es;40 CISTERN YES NO WELL YES -) WELL PERMIT = /Ul.Q SYSTEM SIZE: Septic tank material is constructed ofeJA/C(?F and has 9670 gallon. capacity. FIELD: Trench ,v/A square feet or Bed ,9,700 5r square feet YEAR INSTALLED T jt52-1975 You are required to draw a diagram of the system on the reverse side of this form in black ink only and indicate location, 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 tins time on the parcel of ground identified by the above legal description and further states that the syste i• is not in good working order and to the best of his/her knowledge i ' is no 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 le II action to perjury as provided by law. fie, /off , N DA" E OWNER Subscribed anfl`sworn to before me this / day of r c2-00,ay. ` b i ) •1 b Ia:w% /,&) I Anne) Oh. Witness my hand and official seal. Y1y_ commission expires: / d--001/ 9 - / a - Qa DATE NO .ARY PUBLIC STATEMENT OF EXISTING REVIEWED BY ENVIRONMENTAL HEALTH SPECIALIST ei-c9`tt LVI'CUt u ._At Ivir i rely ivy. NW Celt SEC 24♦ A PORTION OF SHEET 1O1 NO.5 PIN THE SW I/4, SW l/4, SECTION 28, T2N, R67W OF THE 6TH P.M., IN WELD COUNTY. COLORADO. �I 1 I ci I I I LEGEND a 1^ � N89'55.58 E 1334.04' `!� • PINS FOUND 5- O PINS SET I- b aI 15 1.1) v . wv Nom I 4• / `O-41 T`` 28.588 ACRES •ry'l^rp CY 1 ■ iv i T -I MryI' o .g �ry nit 0III vi ip pQIza OI I M f' N W It' c ... it, ?3 ��CC u LOT �A� co SCALE Cu 300' BOTH ROADS I I` r.., _, 8 r ° .,60'R.O.W- 1"'-- 10.629 ACRES 3� - _ 30' -1 - - — Stanle o SEC. COR NO. 5 P _ • 'A.:/!' 660.00' _ _ S1�4 NO 5SEC 28 19 Cc&5; 1 N90.00'00'IM TO COUNTY RD.NO. 16- -1/ re LOT A11= 10.624 ACRES ' . LOT Bun 28.388 ACRES TOTAL 39.012 ACRES - ritr(t.• tom_ DEPARTMENT OF PUBLIC HEALTH & ENVIRONMENT —' 1555 N 1 u s Greeley, CO 80631 Website. www.co weld co us 'P VAdministrations. (970) 304-6410 Fax (970) 304-6412 Public Health Education &Nursing (970) 304-6420 C Fax. (970) 304-6416 /�* ^ Environmental Health Services. (970) 304-6415 COLORADO Fax (970) 304-6411 September 23, 2002 William Wimmer 7124 CR 17 Ft. Lupton, CO 80621 RE: William Wimmer No: 02-087 Permit No.: SE-0200086 On 09-18-2002 an evaluation of the existing individual septic disposal system at: 7124 CR 17, Ft. Lupton; Section 28, Township 02, Range 67, was conducted by Deborah Blandin, an Environmental Specialist of this department. The existing individual septic disposal system is of sufficient size and capacity to adequately handle the proposed load. This evaluation is based on a final treatment capacity for a 3 bedroom residence. Be advised, neither the County of Weld nor 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. This inspection was conducted for the purpose of determining compliance with current regulations and for detecting health hazards observable at the time of inspection. This does not constitute a warranty that the system is without flaw or that it will continue to function in the future. Inspections requested during periods of snow cover and high soil saturation may be of questionable value to potential buyers due to adverse conditions. Evaluations based on Statements of Existing (S.O.E.) relies on information the property owner provides, under oath, indicating current status of the system and representing to the best of his/her knowledge the system is not failing to function properly. If we can be of any further assistance, please contact our office at (970) 304-6415. Sincerely, Deborah Blandin Environmental Health Specialist FIELD INSPECTION FORM ISDS Request No: 02-087 Plan Referral No.: Date Received: 09/12/2002 Received By: DYC Fee: $95.00 Date Inspected: Owner Name: William Wimmer Phone of Contact Person: 303.833.5980 Mailing Address: 7124 CR 17 Ft. Lupton, CO 80621 Site Address: 7124 CR 17, Ft. Lupton, CO 80621 Legal Description: PT PT Sec 28. Twn 02 N, Rng 67 W Subdivision: Lot Blk Flg Water Supply: CWCWD Residential/Commercial Total Acres: 28.38 Permit on Record: WIMMER, WILLIAM & HANS Permit No: SE-0200086 S.O.E.: Y System Size: Tank 0/00 gallons Trench square feet ed a700 square feet Percolation Rate: minutes per inch SoilType: LI /fl Oaf Engineer Design: Yes/No Percent Ground Slope Direction The septic system identified abo IS/ of sufficient size to accomodate the psased aalate structures) served by this system. Current Flow Additions Proposed Total Description: HOUSE RiE HOUSE Persons: �'1 0 Bedrooms: �'? . Bathrooms: `71-1. N i 1.75 Bsmt Plumb: N /�C �,,;p i i'9 (The he e -•st e septic 2,4e is Re ir• e tnmen t have th lowi altera ' math•-tu_______ acc odat the posed a er • ns to the s ure(s) ser Envit`onmental Health Specialist Date • forms Lsdsttip 7 ISDS NO: ca-n DATE RECEIVED: Q-(a- RECEIVED BY: C../� FEE: O QS . Q D COLORADO INDIVIDUAL SEWAGE DISPOSAL SYSTEM EVALUATION SITE ADDRESS OR LOCATION: -.j t.aL{- C iZ �� F* - Ltic Q t-t.)fl PARCEL NO: LJ, I a C7 0 C O 3 THIS CAN BE OBTAINED FROM THE I LO OFFICE AT (970) 353-3845 EXT 3650 OWNER: 1& 1 (Yl (vv../ jD \ &e m ` l RN1S PHONEC ?3- MAILING ADDRESS: -11a4 C h LAS k1/4-4111-\ C -U'a-) CITY STATE ZIP ir, APPLICANT NAME: UO �k.1 ... Y� � 1MYI,VI¢HONE:��j_)p33 �cl-y APPLICANT ADDRESS: (IF DIFFERENT FROM OWNER) CITY STATE ZIP PHONE: ALT FAX: LEGAL DESCRIPTION: PT:SW`t PT: q-SEC: a TWN: C7 N RNG:(P7-W SUBDIVISION: LOT: BLK: FLG: WATER SOURCE: C c1 - ACRES: �O • ORIGINAL OWNER OF SEPTIC SYSTEM: - J,X. l fvl rY\ Y C.C'1 l t-6e m44-enS PERMIT NO: OW �� SOE: YES / NO DESCRIPTION OF STRUCTURE (i.e. House, Shop, Modular): CURRENT FLOW: ADDITIONS: PROPOSED TOTAL: DESCRIPTION: 6v.SQ� PERSONS: BEDROOMS: Q. 5 a . BATHROOMS: 15lint BASEMENT PLUMBING: fV NEITHER THE COUNTY OF WELD NOR ANY OF ITS A NTS 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. lei WELD COUNTY DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT i 555 'FORTH 17TH AVENUE GREELEY, CO 8063 I PHONE (970) 304-6415 FAX (970) 304-6411 Permit 4: SP-0000190 Sec/Twn/Rng: 28-02-67 Status: Owner: WIMMER WILLIAM Applied: 04/03/2000 - Applicant: WIMMER WILLIAM K HANS Issued: (4/05/2000 W Permit Type: KNE C=Cnmmerc•isa, R=Residential r NEW. REPair, Aaul T Finaled: L �— � Parcel #: 1311-28-0-00-032 / Location: 7124 WCR 17 FTL Legal Description: Installer: L • I L Description: MOBILE HOME Commercial: N Residential:Y Acres: 29.38 # of Persons: 2 Basement Plumbing: N # of Bedrooms: 3 Bathrooms - FLIT 2 3/4: 0 1/2: 0 Water Public: Y Water Source: CWCWD Water Private: N Cistern: N Well: N Well Permit #: Percolation Rate:6. Limiting Zone: 8 ft 0 in Description 'T Ground Slope: 0 Dir: Soil Suitable: (Y/N) Y Engineer Design Required: i YIN) N In 100 Year Flood Plain: (Y/N) N Minimum Installation Chambers Septic Tank: 1000 gallons Absorption Trench: 948 square feet or Absorption Bed: 1230 square feet Actual Installation / 03 Septic Tank: /OOO gallons Absorption Trench: -4--63a" square feet 2 3 Absorption Bed: square feet Design Type: /0,8 /rP tc-� NOTICE The issuance of this permit dt,rs nor imply compliance with other state.country or local regulatory or building requirements. nor shall it act to certify that the subject system will operate to compliance s.iih applicable state. counts and local regulations adopted persuant w Article In. Title 25, CRS as amended. except far the purpose of establishing tinal approsal of installed system for issuance of a local occupancy permit persuant to CRS 1117325-In-III ?t This❑ermit is not transferable The Weld Courts Department of Public Health and Environment reserves the right to impose additional term.and ondiaonc required io meet cur regulations on a continuing basis Final permit approval wits contingent upon the final inspection al the completed system hs the weld Counts Department of Public Health and Ere.ircinmeni X /' ¢—0(//6"--- V--1 7-0 U Environmental Health Specialist Dare Finn S_FINAL j d 1 • WELD COUNTY DEPARTMENT OF P! IBLiC HEALTH AND ENVIRONMENT 1555 NORTH 17TH AVENUE GREELEY, COLORADO 80631 • PHONE (970) 304-6415 FAX (970) 304-6411 Permit M: SP-0000190 Sec/Twn/Rng:28-02-67 PERMIT Owner WIMNWR WILLIAM & HANS Applied: 04/03/2000 Applicant: WIMMER WILLIAM & HANS Expires: 03/29/2001 Permit Type: RNEW C=Commercial, R=Residential — NEW, REPair, VauLT Parcel #: 1311-28-0-00-032 Location: 7124 WCR 17 FT LUPTON Legal Desc: Description: MOBILE HOME Commercial: N Residential:Y Acres: 29.38 # of Persons: 2 Basement Plumbing: N k of Bedrooms: 3 Bathrooms - Full: 2 3/4: 0 1/2: 0 Water Public: Y Water Source: CWCWD Water Private: N Cistern: N Well: N Well Permit Number: Percolation Rate y(e„ I Limiting Zone79 ft in Description % Ground Slope / Direction W Soil Suitable (YIN) Y Engineer Design Required (YIN) j In 100 Year Flood Plain (Y/N) 7 From the application information supplied and the on-site soil percolation data the following minimum installation specifications are required: Chambers Septic Tank Jed() gallons, Absorption Trench 9VS square feet 3 / or Absorption Bed /230 square feet cio In addition, this permit is subject to the following additional terms and conditions: ,/// w c� o�,lcc /5 iee7 �,� 7,I, • �P� • NOTICE This permit is granted temporarily to allow construction to commence. This permit may he revoked or suspended by the Weld County Department of Public Health and Environment for reasons set forth in the Weld Counts 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 constitute assumption by the department or its employees of liability for the failure or inadequacy of the sewage disposal system. Thispermit is not transferable- Before issuing final approval of this permit 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 conlinuging basis. Final permit approval is contingent upon the final inspection of the completed system by the Weld County Department of Public Health and Environment. This permit expires one year from the application dates /✓� �te ✓ plv" </ SOU Q\`) .\ 6° High Plains Engineering '. 1-,„ 735 Ce- ter .d.enue • Fort Lupton CC 80521 ?hone 3=_-857-9230 • Fax 303-857-3233 • PROPERTY A.DCRESS 7/2.L( w e 2 R R !7/ iv A) CO I'G4.L/ PROPERTY OWNER: +� n NAVE £ JJ iJ , mem e 4 0 ADDRESS 7/ q W e i2 / � f < G L /0 Co ?Oct e/ PHONE 503 - $ 6 - G3 // S - -I'ON ANC SWELLING GROLNDWATER AILF,.4 � . SMEARED SURFACES PEAIOVEC:✓Y_:—NC ENCCLN_REC O 7 8 D -Th -C JAX:ML'M SEASC'.-L SANE CR GRAVE_ ACCEC:_"ES v C WATER TABLE IF NC ENCCLNTERE" DATE ANC TIME PRESOAK WATER ACC=: PROFILE: 3-/9-2 cots 2'Do IS AREA BELIEVED TO BE SLBJEECT TO SEASONAL AMOUNT OF PRESOAK WATER ADDED "OAL_ONS): FLUOR ATICNS WH:CH COULD RESULT 1 O q, II a .�$ SESONAL WATER TABLE WITHIN 9' OF rRFACE'. _5 NO CATE AND TIME PERCOLA ICN TEST '.S 'ARTED: -20 - ZOe.a >-3o P. i.-J. __ S __LCPE T _RMiN.•'.-1ON IN AESCr°TiONI :10 WATER PEMA.N IN HCLE AFT_ . T )V-R_ _ NIGHT SWELLING PER _O:: _. - 'EA e TO THE (,DIPE.CT[ON) HOLE 1 YES v NH HCLE 2 ENG�UNTE=ED HC m≥FFEET. L_ ., •.. I HOLE 4. 2E ".C I ES- M.-TED DEPT L.! iF NCT ENCCUNT_r_ N PROFILE: r'oLE z NO 'HO! E 5 YEC ^.3 ROOLA , .CN RCE �cc CF BEDROCK _ SANDSTONE PFPCCLA`ON RATE WIN. 36 DEEP HOLE ' W' —_LA sTCNE _ StTS ONE 36 " DEEP HOLE 3c DEEP HOLE OTHER y/ S :CROCK =RACTLRED CR WEATHE 3c„ DEEP HCL_ 36" DEEP Y`s vo HOB= :5 BEDROCK SEL:VED TO 3E PERMEABLE? 36" DEEP HOLE 3 . H/a ,PERC RATE <50 MN./IN.) AVERAGE 4—L-1`;' ( —YES—NC FLE NO. Oo_Oz3a __ • • IMMF0F4iA T 10N (CON- rFC. _E , ..�_ - EZ =LASLF:ED USING UNIFIED SYSE AST\.4 ==1LE 'HOLE LOG L_ i I � 5ANoy L(... 7 (5C) I 6 I H a 9 �I I "ER-1r C,q—hrry - HA 1^ nE O J IM `nA ION S 00F\F U- AND C0MPLETBEST E - _ Nr - r RFORMED IN Or MY KNTH = ANC 4L c5-S DFR RT r 0C N -n C0l N HEA-T� A., 1_ c- cSE = C4 UNDER MY Ste==°'VISI0N. I^�L 'J Dl r'_ Sc NAGE DIS .,SAL - __ _A i JN� ., M . _. /r -te9 REG/Sr c,,ej aVe a High Plains Engineering SIGNATURE 12330 .0i 1 735 Denver Ave. • DATE Ft. Lupton. CO 806'1 FE.& LSx' 303-857-9280 i_ SITE MAP 7 , --N �'hcr�' r per- 67F,.r}i,v' 1.3(4 \Perc Profile Hole 5 • ,..--.4_,;, 1 .->-- L ChF74•7:th 5/4E-PS Pere Holes —4. i ,3„zti cLrLEiz --2-1-A2 rtt--14gr0A v\i 1 rF D - - P 34-O ___________÷,p- . - 'A g'V" \ Hows0 r il l 7 / -7/ z 4 I.Q.'C)? 2 7 [-Cie- 7- L & Pnk C� ec;&2/ 7 1 WELD COUNTY DEPARTMENT OF PUBLIC HEALTH L ENVIRONMENT 1555 NORTH 17TH AVENLE. GREELEY, CO 80031 PHONE: (970) 304-6415 FAX: (970) 304-6411 • APPLICATION / RECEIPT Initials: CS Permit Number: SP-0000190 Receipt Number: HAP000230 04-03-2000 Amount: S315.00 Payment Method: Check Notation: 4604 Owner Name: WIMMER WILLIAM & HANS Applicant Name: WIMMER WILLIAM & HANS Parcel Number: 1311-28-0-00-032 Site Address: Location: 7124 WCR 17 FT LUPTON Total Fees: $315.00 Total All Payments: 315.00 This Payment: 5315.00 Balance: $0.00 Account Code Description Amount 256041400-4221-400 New Septic Permit $315.00 256041400-4221-400 Repair Septic Permit 50.00 25604 1 400-4221-400 Vault Permit $0.00 256041400-4730-400 Potable Water $0.00 Description: MOBILE HOME Commercial: (Y/N) N Residential: (YIN) Y Acres: 29.38 Number of Persons: 2 Basement Plumbing: (Y/N) N Number of Bedrooms: 3 Bathrooms: Full - 2 3:4: 0 1/2: 0 Water Public: lY/Nl Y Water Source: CWCWD Water Private: (Y/N) N Cistern: (YIN) N Well (YIN) N Well Permit Number: NOTICE Applicant acknowledges receipt of the individual sewage disposal system guide and that the completeness of this application is conditional upon further mandatory and additional tests and reports as may he required by the Weld County Department of Public Health and Environment to be made and furnished by the applicant or by the Weld County Department of Public Health and F.osironntent for purposes of the evaluation of the application: and the issuance of the permit is subject to such terms and conditions as deemed necessary to insure compliance with rules and regulations adopted under article 10. tole 25. CRS as amended. The applicant certifies theat the proposed system will not be located within 400 feet of a community sewage system. The undersigned hereby certifies that all statements made, information and reports submitted herewith and required to he submitted by the applicant are. or will be. represented to be true and correct to the best of my knowledge and belief, and arc designed to be relied on by the Weld County Department of Public Health and Environment in evaluating the same for purposes of issuing the permit applied for herein- I further understand that any falsification or misrepresentation may result in the denial of the application or revocation of any permit granted based upon said applicaion and in legal action of perjury as provided by law. This application expires one year from the si nature da e. - wner/Applicant Date Form RT_IIAPP `-7`ttj Cat at', . SEPTIC INFORMATION FORM Wi , c To obtain an 1.5.D.S. permit, one must file an "Application for Individual Sewage Disposal System" at the Neld County Environmental Projection COLORADO Services office, and pay the application fee. A "repair" fee shall be charged for the expansion. replacement, or repair of an existing system. The following information must be provided on the septic information form: PARCEL NO.:J3 i ( Zga© 003 2 THIS CAN BE OBTAINED FROM THE ASSESSOR'S OFFICE AT (970) 353-3845 EXT. 3650 PROPERTY OWNER/LLI Al/Y1 WivIMn? - cf-- n4,05 /4 //'/ A4 oil - MAILING ADDRESS 7/Z 1- 1Vc g I7 CITY in LL'PTO-AJ STCn ZIP 0062--/ HOME PHONE (3(91 x,33 -51FaORK PHONE (30 ?52/¢ZDFAX (303) U,3Y-365lp APPLICANT NAME hAtL/A'ill 114771 ttjC r MAILING ADDRESS 1/Z 4 loc. ,e 17 CITY FM LOPTo✓ ST Co ZIP 67)67/ HOME HOME PHONE (3O g-3l-,�IJ�00 WORK PHONE (3r5I -5Z-L1Z6FAX (3431 83.3 366,5".E, LEGAL DESCRIPTION PT544 P1544 SEC ZS TWN 2 _ RNG 107 ACRES Of/-3g SUBDIVISION LOT BLOCK FILING DESCRIPTION CF BUILDING (ex: House. Mobile Home. Modular. Shop. Office) Noe/c.f. 4r c SITE/LOCATION ADDRESS 71 Z + we 2 17 Er-, Lo t ro^) (?D is o e _ I DIRECTIONS TO SITE Ni-o) 155 ScuT k -ro t'4Cv Ce WE-ST- To wca n Se T Lf G 2 1 Lv IA)15 T-) To Ca X17 No cTW >Y8 m I. To R Dt EC sS_e NEW PERMIT k REPAIR PERMIT 5315 5315 IF OBTAINING A REPAIR PERMIT, PLEASE LIST PREVIOUS OWNERS OF THIS PROPERTY CENSUS TRACT RES1DENTIAL(tE NO COMMERCIAL YES / NO NUMBER OF PERSONS 2- EASEMENT PLUMBING _YES / NO NUMBER OF BEDROOMS 3 BATHROOMS: FULL 2- 3/4 1/2 WATER SUPPLY: PUBLIC CE)/ NO UTILITY NAME&Fi✓ 4t. )2' J .DC '' l44TtiK---ACCT. PRIVATE YE / NO CISTERN YE _ WELL YES® WELL PERMIT # • Please draw a map to your property. vyLQ `C\ 117 041 N 3� Hello