HomeMy WebLinkAbout20162395.tiffWILk
COLORADO
n -D COUNTY DEPARTMENT OF PUBLIC
L..ALTH AND ENVIRONMENT
1555 N.17T" AVENUE
GREELEY, COLORADO 80631
PHONE: (970) 3046415
FAX: (970) 304.6411
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ORG PERMIT #
REPAIR #
LOAN #
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STATEMENT OF EXISTING FOR SEPTIC SYSTEM
(PLEASE FILL OUT IN BLACK INK ONLY)
PARCEL NO. / 3 O 9.a b no 4i 3
PROPERTY OWNER Po
MAILING ADDRESS , S-2. I, 7 Rd
HONE NO. (_301$57-z8!
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City State
go 6 Z/
Zip
DESCRIPTION OF BUILDING (ex. house, mobile/mo/dularryhome, shop, oraee)./ 4 n c7 /d r -
STTFJLOCATION ADDRESS / 7 /P d ( 8 To ! vrO%0N ffDIZ/
LEGAL DESCRIPTION
SUBDIVISION
CENCUS TRACT
City State , Zip
PT SECTION ' - TOWNSIBP2eV RANGE 44 w
LOT BLOCK FILING _
LOT SIZE/ACRES S 4 c i e
COMMERCIAL_Ma S RESIDENTIAL y NO
NUMBER OF PERSONS f, -j BASEMENT PL
BEDROOMS f S . BATHROOMS - FULL • 3/4 1/2
WATER SUPPL PUBLIC O NAME
PRIVATE 0 WELL /NO CISTERN YES/NO WELLCISTERN# 2? 7/
SYSTEM SIZE: Septic tank material is constructed of l o .v cref'and has gallons capacity.
FIELD: Trench 1< square feet or Bed square feet YEAR INSTALLED / 9 7e' S
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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 this time on the parcel of ground identified by the above legal d riptioo and further states
that the systemRs not In good working order and to the best of his/her knowledge i fns failing to function proper
I further understand that any'falsification or misrepresentation may result in revocation of any permit granted based
upon this information hereby submitted and in legal action for perjury as provided -by law.
/o//°l lay
DATE
Subscribed sworn to before me this
By
Witness wy han and °M eial seaL corn
10%9/0 L/
'1'ARY
DATE NOPUBLIC
STATEMENT OF EXISTING INSPECTED & REVIEWED BY
PWVTDf1NMDW'r A T nre rTQ Corn AT TCT n A TT
Form No.
GWS-25
APPLICANT
OFFICE OF THE STATE ENGINEER
COLORADOg., 13DI13 VISION erman St, OF WATver, ERo RESOURCES
818 03
(303) 866-3581
DONALD & CHERYL HACKETT
15267 ROAD 18
FORT LUPTON, CO 80621-
EXST
WELL PERMIT NUMBER 63373 -F
DIV. 1 WD2 DES. BASIN MD
(303) 857-2813
CHANGEIEXPANSION OF USE OF AN EXISTING WELL
APPROVED WELL LOCATION
WELD COUNTY
SW 1/4 SW 1/4 Section 22
Township 2 N Range 66 W Sixth P.M.
DISTANCES FROM SECTION LINES
200 Ft. from South Section Line
1200 Ft. from West Section Line
UTM COORDINATES (Meters,Zone:13,NAD83)
Easting: Northing:
ISSUANCE OF THIS PERMIT DOES NOT CONFER A WATER RIGHT
CONDITIONS OF APPROVAL
1) This well shall be used in such a way as to cause no material Injury to existing water rights. The issuance of this permit does not ensure that
no injury will occur to another vested water right or preclude another owner of a vested water right from seeking relief in a civil court action.
2) The construction of this well shall be in compliance with the Water Well Construction Rules 2 CCR 402-2, unless approval of a variance has
been granted by the State Board of Examiners of Water Well Construction and Pump Installation Contractors in accordance with Rule 18.
3) Approved for the change/expansion of use of an existing well constructed under permit no. 82978 and repermitted for expanded uses under
permit no. 227271.
4) Approved pursuant to CRS 37-90-137(4) and the findings of the State Engineer dated September 29, 2005.
5) The use of ground water from this well is limited to ordinary household purposes inside one (1) single family dwellings, lawn and garden
irrigation, and a commercial dog kennel.
6) The pumping rate of this well shall not exceed 15 GPM.
7) The average annual amount of ground water to be appropriated shall not exceed 1.16 acre-feet.
8) Production is limited to the Laramie Fox Hills aquifer.
9) The entire length of the hole shall be geophysically logged as required by Rule 9 of the Statewide Nontributary Ground Water Rules.
10) The owner shall mark the well In a conspicuous place with well permit number(s), name of the aquifer, and court case number(s) as
appropriate. The owner shall take necessary means and precautions to preserve these markings.
11) A totalizing flow meter must be installed on this welt and maintained in good working order. Permanent records of all diversions must be
maintained by the well owner (recorded at least annually) and submitted to the Division Engineer upon request.
12) This well shall be constructed at least 600 feet from any existing well, completed in the same aquifer, that Is not owned by the applicant.
13) This well shall be constructed not more than 200 feet from the location specified on this permit.
14) Pursuant to CRS 37.90-137(9)(b) and the Denver Basin Rules, no more Than 98% of the ncntribulary ground water withdrawn annually shall
be consumed and the well owner shall demonstrate to the reasonable satisfaction of the State Engineer that no more than 98% of the water
withdrawn will be consumed.
15) This well Is subject to administration by the Division Engineer In accordance with applicable decrees, statutes, rules, and regulations.
16) The issuance of this permit hereby cancels permit no. 227271.
NOTE: The ability of this well to withdraw Its authorized amount of water from this non-renewable aquifer may be less than the 100 years
upon which the amount of water in the aquifer is allocated, due to anticipated water level declines. Q. eG,(5
APPROVED
JLV
Receipt No. 0541843
h /%'!/ 2 Gam- . / 2
1
State Engineer By
DATE ISSUED 09-29-2005 EXPIRATION DATE 09-29.2006
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