HomeMy WebLinkAbout20141618.tiff SEPTIC PERMIT INFORMATION FORM
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COLORADO To obtain an I.S.D.S.permit,one must file an"application for Individual Sewage Disposal System"
at the Weld County Environmental Health 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.
COMMERCIAL PERMIT x _ RESIDENTIAL PERMIT
NEW or REPAIR $850.00 NEW or REPAIR $750.00
VAULT PERMIT MINOR REPAIR PERMIT
NEW or REPAIR$250.00 $100.00
PARCEL NO.: / 2-110 Z G O00O (12 DIGIT NUMBER)
LEGAL DESCRIPTION: SECTION /Z TOWNSHIP RANGE 6,Lo ACRES 3 S
SUBDIVISION Pori" a P IVt I(q LOT BLOCK FILING
THIS INFORMATION CAN BE OBTAINED FROM THE ASSESSOR'S OFFICE AT (970) 353-3845 EXT 3650
SITE ADDRESS
DIRECTIONS TO SITE -Sc a �, Q S -&Ak 11c 6C
PROPERTY OWNER: AAc.do.rlco ?8` rd l°u r, (.0 rrn dolor,
MAILING ADDRESS: .Q. Ras, )73 )7 CITY b-en✓et— ST (...t ZIP 007
HOME PHONE: (7W) tart q (ocnof WORK
I PHONE(3e3) If')f3 Yt,( 8 FAX( )
EMAIL ADDRESS: Tr ,AAtS/hbd.v�rl� p. 0.nactarL/c.o /, C�r . I/�� II
APPLICANT NAME: t)G�1��{' 6PiASIa)/ Land.-i -L g.nicl'erc
MAILING ADDRESS: 35 I Z- JJCarson/ r_CITY E Jan S ST CC) ZIP 9O(D uJ
HOME PHONE: (q )) 330 -6 es-5---WORK PHONE( ) FAX( )
EMAIL ADDRESS: 7�DESCRIPTION OF BUILDING(EX: HOUSE,MOBILE HOME,MODULAR,SHOP,OFFICE) &e4 Ce rrm era omj 'dI ty
IF OBTAINING A REPAIR PERMIT,WHAT IS BEING REPAIRED?
NUMBER OF PERSONS 7 IN FLOOD PLAIN AREA? YES/I�
NUMBER OF BEDROOMS ) PERCOLATION HOLES MUST BE MARKED FOR
INSPECTION OR A$50.00 FEE WILL BE CHARGED
BASEMENT PLUMBING YES/9
CENSUS TRACT
BATIIROOMS: FULL
PUBLIC WATER SUPPLY YES/qsu, NAME
PRIVATE WATER SUPPLY YES/NO WELL/ ISTERN PERMIT#
TX Result Report P 1
02/06/2014 09:12
Serial No. A0ED012005567
TC: 137881
Addressee Start Time Time Prints Result Note
13038662223 02-06 09:08 8g 00:03:43 cc�1010/010 OK gg
Note MZX: Mixedyd Ori final-TX. CALL:OManualtTX.Original Size
CSRC:9FWD:FForward. PC: pC-Fax.
ILY: Relay. HBX:t Cded onfidential. :Direction.Bulletin. SI P rSIPRFax.FIPADit:FIP address•Fax.T%r
Result OK: Communication OK, S-OK: Stop Communication, PW-OFF: Power Switch OFF,
TEL: RX from TEL, NG: Other Error, Cont: Continue, No Ans: No Answer,
Refuse: Receipt Refused, Busy: Busy, M-Full:Memory Full,
LOVR:Receiving length Over, POVR:Receiving page Over, FIL:File Error,
DC:Decode Error, MDN:MDN Response Error, DSN:DSN Response Error.
COLORADO DIVISION OF WATER RESOURCES effete Lama Only
oEPARrMENT OF NATURAL RESOURCES I Fenn OWS<3(07/2013)
1213 SHERMAN aTFRM 821,OEN\/ER.CO 80203
dw>ne tote COMB
3l BBna581 neat Yi03)S »>s o e
GENERAL PURPOSE
Water Well Perm It Application
The Paneled
for must n W no/neuter on
ramose oda prier m compilation
an.venerated.types or in btoek or C<n.inn_1.Nam. rodent Information
Inloation B.Use Of Wall(chock applicable boxes)
Anadarko Petroleum Corporation Alias,r detailed description Mopes applied for.
_ p l.wuama o i p Pwafarine-+>...a.
(prod
PO Bo%173779 0 Murvdpai 0 Gantrormot(production n
Denver se m' 0 irrigation O Onwr(Pasahent rmi lawen
PC) 602173799 Cennmenial
.0-02 -00 (� intro 7_Wall Oats 01.0Poaatl)
720-92 96 000 Itdsb- hb enadarko-com Moorage __ sw.nma..2. Type Of Application(check applicable boxers) 15 mm,ara+na�, ePm uP[0 19 n' eon-feet
® Construct new welt 0 an..amnng well a
I=I Raplarw...Winn well o increaseChange or increase
B420 fe Thanes mums(aquifer) o Raapwloation<erpired rennin S.Land On Which around Waterl Will Used -
OOk:C Weil 11 Other;
3. Refer-ro(H applicable) - - Lapel PooglPtlon of Land(...y en poumwo a..mr..�.O:
Nil pants •.a..-coneess•
- Location Of Proposed Well
Wald NF 1a....,. NE it. la loan Or cap pneawn,a,mrnaeared neap that atoml..sl.a.a area.)
•bpr canes I B.
2 o.seams. I3 oaPip IXti Cl ere.
L...-go
® j d c r,r .nor onset
[amen us re bndlr lose
a - r•r ++.a..wmnr.n.a.r. ire.
283 er..d,,,o a^'nmr ]NnOua tam. a,,..imEcW
•a•a"n"eiro'•r� 9.Proposed Well Thriller License Al(o tlonap:
. Cast arc direction 10.filen or Entered Nea..q p
^- ensam .. .. .n.o. -. .. .. Apeincatu ) tor AUB1er,in olos e Prom,
t .'T +� ..in... ....... rrn i, doom.which
of fa pu atata is ere herein wnvedeme anon pursuant Is mn to C.R�.ga c,which Is p;M1 ahabin v a dons t to hmean or w the to C.R.S.
17935 CR 35, Platteville. CO 80651 10•i re etas)- aw I" �. ataeemano trorvlq know the contents
oparonee ens nes exam.)biennium n Mina tenons Minimum m chest PPs , son a-l state Martha
the w men knawl.dPa.
q.deddonnaasm... ,...tram •-.•-o-,.m Pr.>k 1. .- .. wonrn+r,..r..>
p�n>a.. a Farrrat mono
+a mu •�` 02/03/2014
an,enp pa d Pri9ab -
Y• ml onager, Landmark Builders, Inc._ r.om,me CO Use On —
5. Pa al On Which Well Will Be nernfammeoLocate a room a-.noes .1005•'m"as I nap en su.r.dr.._
(PLEASE AnnealAnnealA cunnsaT PESO FOR THE SuojECT PARCEla Ramlpt a,se only
O. Legal O.eoiptlon Ono ar Rm.....m.,.nw..aq_
Part of N 1/2 of NE 1/4 of Sac 2 t 3N Ft 66W
Weld County Colorado
a- assn.rnped I C. q.,,..
35
—
O. wen,a..a it,my a re on in.pear, ICU.Eels no t.••.,in s,.r..ie> am
E. Srm pond rs(m.e,r>:
COLORADO DIVISION OF WATER RESOURCES Office Use Only I Form GWS-45(07/2013)
DEPARTMENT OF NATURAL RESOURCES
1313 SHERMAN ST,RM 821, DENVER,CO 80203
Main: (303)866-3581 Fax:(303)866-2223 dwrpermitsonline(c6state.co.us
GENERAL PURPOSE
Water Well Permit Application
Review instructions on reverse side prior to completing form.
The form must be computer generated,typed or in black or blue ink.
1. Applicant Information
Name of applicant 6. Use Of Well (check applicable boxes)
Attach a detailed description of uses applied for.
Anadarko Petroleum Corporation
❑ Industrial ❑ Dewatedng System
Mailing address ❑ Municipal ❑ Geothermal(production or reinjection
PO Box 173779
❑ Irrigationcity State Zip code ❑ Other(describe):
Denver CO 802173779 Commercial
Telephone (area code&number) E-mail(online filing required) 7, Well Data (proposed)
720-929-6000 trish.eshbaug@anadarko.com Maximumpumpingrate Annualamounttobewithdrawn
2. Type Of Application (check applicable boxes) 15 gpm
up to 1/3 acre-feet
❑ Construct new well ❑ Use existing well Total depth Aquifer
❑ Replace existing well ❑ Change or increase use 420 feet Laramie Fox Hills
❑ Change source(aquifer) ❑ Reapplication(expired permit) 8. Land On Which Ground Water Will Be Used
❑ COGCC Well ❑ Other: Legal Description of Land(may be provided as an attachment):
3. Refer To (if applicable)
Well permit# Water Court case#
Designated Basin Determination# Well name or#
4. Location Of Proposed Well
County (If used for crop irrigation.attach a scaled map that shows irrigated area.)
Weld NE 1/4 of the NE 1/4 A. #Acres B. Owner
Section Township N or S Range E or W Principal Meridian
2 3 ITI El 66 0 0 C. List any other wells or water rights used on this land:
Distance of well from section lines(section lines are typically not property lines)
283' Ft.from F;N 1-s 223' Ft.from ME❑W
For replacement wells only—distance and direction from old well to new well 9. Proposed Well Driller License#(optional):
feet direction 10. Sign or Entered Name Of Applicant(s)Or Authorized Agent
Well location address(Include City,State,Zip) ❑Check it well address is same as in Item 1. The making of false statements herein constitutes perjury in the second
degree,which is punishable as a class 1 misdemeanor pursuant to C.R.S.
17935 CR 35, Platteville, CO 80651 24-4-104(13)(a). I have rea a statements herein,know the contents
thereof nd state that the a true'to my knowledge.
Optional: GPS well location information in UTM format You must check GPS unit for Sign or t name(s)pf person( ubmitting application Date(mm/dcl/yyyy)
required settings as follows:
02/03/2014
Format must be UTM
If sign' dnt name an tit
El Zone 12 QV]Zone 13 EaSting
Units must be Meters Davd Grigsby, en ral anager, Landmark Builders, Inc.
Datum must be NADa3 Northing O Ice Use On
Unit must be set to We north
?EYES USGS map name DWR map no. Surface elev.
Was GPS unit checked for above
❑ Remember to set Datum to NADB3
5. Parcel On Which Well Will Be Located
(PLEASE ATTACH A CURRENT DEED FOR THE SUBJECT PARCEL) Receipt area only
A. Legal Description(may be provided as an attachment):
Part ofN1/2ofNE1/4of Sec 213NR66W
Weld County Colorado
B. #of acres in parcel C. Owner AOUAMAP
35 WE
WR
D. Wll this be the only well on this parcel? E YES❑I NO(if no list other wells) CWCB
TOPO
E. State Parcel tO#(optional): MYLAR
SBS DIV WD BA MD
f;"r fir-77 7 1 rl k 73 NS• ENGINEERING5 ,
1011 42nd STREET + EVANS, CO 80620
Phone (970) 353-4463 Fax (970) 353-9257
Dec 13, 2013
Colorado Division of Water Resources
Department of Natural Resources
1313 Sherman St RM 818 Denver CO 80203
To whom it may concern:
Anadarko E & P Services is submitting the accompanying well permit application
for a 35 acre parcel within an existing 280 acre parcel located in the part of the
North %2 of Sec 2 T3N R66W. The proposed 35 acre parcel that the well is being
applied for is presently going through a Recorded Exemption process with Weld
County. The proposed 35 acre parcel is going to be in part of the N 1/2 of the NE
1/4 of Sec 2 T3N R66W. An actual legal description of the proposed 35 acre
parcel will be available when all of the requirements for the Recorded Exemption
process have been met. However, a requirement of the Recorded Exemption
process as well as a Use by Special Review process is that proof of adequate
water is available. The approved well permit will fulfill that requirement. Thank
you for your time. Please feel free to contact me with any questions or
comments.
Sincerely
Eric Wernsman P.E.
COLORADO DIVISION OF WATER RESOURCES Form GWS-57(10/2013)
DEPARTMENT OF NATURAL RESOURCES
1313 SHERMAN ST.,STE 821,DENVER,CO 80203 Application Receipt No.
main:(303)866-3581 httn://water.state.co.us
fax:(303)866-3589
Applicant's Name:
COMMERCIAL DRINKING AND SANITARY WELL WORKSHEET
Review instructions on reverse side prior to completing form.The form must be completed in black or blue ink or typed.
1. Name and Type of Business:
2. Is this application for a new well?
❑� Yes
❑ No If no, is this application for a change of use for an existing well?
❑Yes Pen-nit Number of well(if applicable)
❑ No For wells used for drinking and sanitary purposes prior to May 8, 1972, a field inspection of the well to
verify historical uses may be required. See form GWS-12 Registration of Existing Well and
form GWS-12A Statement of Historical Use for further information.
3. Is the parcel the well is located on(or will be located on)within the boundaries of a water service area(water district,
municipality,water company,etc.)or is water available from another source(such as a well)?
❑Yes If yes, indicate what this other source is
❑� No (name of water district/supplier,or well permit number)
4. Proposed type of disposal system to be used:
❑D Septic tank/absorption leach field
❑ Central System (district name:)
❑ Vault(location sewage hauled to:)
❑ Other(attach copy of engineering design)
5. Water Demand Calculations(for average factors for water demand see below)
Employees
Number of X Number of Gallons X Number of Days Employee = Gallons per Year
Employees per Employee per Day Works per Year
10 X 15 X 365 = 54,750 A
Customers
Number of X Number of Gallons X Number of Days Business = Gallons per Year
Customers per Day per Customer is Open per Year
20 X 5 X 365 = 36,500 B
Other Uses(Note: No uses outside of the building would be permitted for this type of well.)
Type of Use X Gallons per Use per Day X Days per Year = Gallons per Year
X X = C
Total amount of water required:
= Gallons per Year
(A+B+C)
91,250
For wells used for commercial drinking and sanitary purposes on or after May 8, 1972,the total water demand cannot exceed
108,600 gallons(1/3 of an acre-foot)per year.
For wells used for commercial drinking and sanitary purposes prior to May 8, 1972,the total water demand cannot exceed 325,900
gallons(1 acre-foot)per year.
General Guidelines for Water Demand in Gallons per Day
Day Workers at Offices—15 gallons/person/day
Food Service Establishments(with toilet and kitchen wastes)—10 gallons/patron/day
Churches(does not include food service)—5 gallons/seat/day
Overnight Lodging—50 gallons/customer/day
On-Site Proprietor of Overnight Lodging(i.e. on-site owner of a Bed& Breakfast)—80 gallons/person/day
Additional water demand figures may be obtained from a private water consultant or from a technical reference on this subject.
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