HomeMy WebLinkAbout20141605.tiff Form STATE OF COLORADO For Office Use Only
No. 1. O&FICE OF THE STATE ENGINEER
GWS-I 1 818 Centennial Bldg., 1313 Sherman St., Denver, CO 60203
8/2005 Phone— Info: (303) 866-3587 Main: (303) 866-3581
Fax: (303)866-3589 http://www.water.state.co.uS
CHANGE IN OWNERSHIP/ADDRESS
CORRECTION OF THE WELL LOCATION RECEIVED
Review instructions on the reverse side prior to completing the form.
Name, address and phone of the person claiming ownership of the well' F S A 2813
NAME(S): Pr S LL)nidq S l.k)e. S *ten ®asuttNt d
Mailing Address:
479 I �
City, St. zip: 14 LLd snn , ( ..D SO& ya
Phone #
This form is filed by the named individual/entity claiming that they are the owner of the well permitted as referenced above.
This filing is made pursuant to C.R.S. 37-90-143.
WELL LOCATION: Well Permit Number r2:7io9S a Receipt Number:
County W_e Owner's Well Designation 93934 C k /0
(Address) <e h 23664(D
Nr (City) (State) I / (Zip)
G 114 of thej/r 1/4, Sec. 13 , Twp. �_2 N. or Q S., Rang ❑ E. or'�}'f/v , Sirry-t1 , P.M.
Distance from Section Lines: ).O ) Ft. FromR.N. or❑s., ,5(00 Ft. From RTE. or D W. Line.
Subdivision Name f) l cu Lot _ , Block_ , Filing/Unit
The above listed owner(s)say(s) that he, she (they)own the well described herein. The existing record is being amended for
the following reasons:
Change in name of owner 'Change in mailing address Q Correction of location for exempt wells permitted prior to May
8, 972 and non-exempt wells permitted before May 17, 1965.
Please see the reverse side for further information regarding correction of the well location.
I (we)claim and say that r(we)(are)the owner(s) of the well described above, know the contents of the statements made
herein, and state that they are true to my (our) knowledge.
Signat e(s) of then w owner Please print the Signer's Name&Title Date
havid A. Powers 11,-liOR
It is the responsibility of the new owner of this well to complete and sign the form.Signatures of age is ar acceptable if an
on inal letter of agency signed by the owner is attached to the form upon its receipt.
For Office Use Only
ACCEPTEDASACHANGE OF OWNERSHIP
APIptOR MAILING ADDRESS
it t___Da(14
State Engineer Date
Form No. OFFICE OF THE STATE ENGINEER
GWS-25 COLORADO ldg., DI3 VISION erman St.. OFrWATEado 6RoRESOURCES
(303)866-3581 LIC
WELL PERMIT NUMBER 256952 - •
DIV. 1 WD2 DES. BASIN MD
APPLICANT l
Lot: B Block: Filing: Subdiv:RE-3715
APPROVED WELL LOCATION
WELD COUNTY
NE 1/4 NE 1/4 Section 13
MICHAEL KORNMON Township 1 N Range 65 W Sixth P.M.
3127 WCR49 DISTANCES FROM SECTION LINES
HUDSON, CO 80643- 100 Ft.from North Section Line
560 Ft.from East Section Line
UTM COORDINATES
(303)536-9681 Northing: Fasting:
PERMIT TO CONSTRUCT A WELL
ISSUANCE OF THIS PERMIT DOES NOT CONFER A WATER RIGHT
CONDITIONS OF APPROVAL
I 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 16.
3) Approved pursuant to CRS 37-92.602(3)(b)(I)and policy of the State Engineer under the following conditions,for a 5-acre
parcel known as Lot B of the Recorded Exemption no. 3715, more particularly described on the attached Exhibit A.
4) The use of ground water from this well is limited to ordinary household purposes inside two(2)single family dwellings,
the watering of not more than four(4)large non-commercial domestic animals,and the irrigation of not more than 10,000
square feet of home gardens and lawns.
5) Production from this well is restricted to the Laramie Fox Hills aquifer,which corresponds to the interval between 780 feet
and 1050 feet below the ground surface. Plain casing shall be installed and grouted to prevent production from other
zones.
6) The depth to the top of the Laramie-Fox Hills aquifer is approximate. To ensure the exclusion of poor quality water from
zones immediately above the aquifer, plain casing and grout shall extend through the lowermost coal and/or carbonaceous
shale that overlies the Laramie sand portion of the aquifer.
7) The pumping rate of this well shall not exceed 15 GPM.
B) The annual withdrawal of ground water from this well shall not exceed 1.15 acre-feet.
9) The return flow from the use of this well must be through an individual waste water disposal system of the type so that not
less than 2%of the total amount of water withdrawn is returned to the same stream system in which the well is located.
10) This well shall be constructed not more than 200 feet from the location specified on this permit.
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.
NOTE:To ensure a maximum productive life of this well,perforated casing should be set through the ntire produ
f62
uC n[D�
interval of the approved zone or aquifer indicated above. I
ALsAPPROVED n
JLV B
State Engineer XPI TION DATE 5.13-2006
Receipt No.0523123 DATE ISSUED 05-13-2004
Permit Application Change Form
To be used when issuing well permits based upon information other than as received. Please file with final Permit.
Receipt No: 523123
Name of Applicant: KORNMON
Summary of change(s):
THE PROPOSED USES OF I ACRE OF LAWN AND GARDEN COULD NOT BE
APPROVED BASED ON AVAILABLE WATER UNDERLYING THE 5 ACRES OF LAND.
THE PERMIT WILL BE APPROVED FOR 2 HOMES, 10,000 SO FT OF LAWN AND
GARDEN ANI)4 ANIMALS.
Date: May 13, 2004 Signed: —
Print Name: J• cneM cka /
Scanning Cover Sheet
for
Septic Permits
Permit # SP-0600051
Permit Type: Health/Residential/New
Situs Street Address 23934 CR 10
Situs City, State, Zip
Sec/Town/Range: 13-01N-65W Application Status: Fineled
Application Date: 02/21/2006
Parcel # (12 digits) 147313100041-R2938404
Owner Full Name: AJ FINANCE
Owner Address: PO BOX 52
JOHNSTOWN,CO 80534
Owner Phone #: 303-570-6256
•
Contact Name: FINNICK JAMIE
Contact Address: PO BOX 52
JOHNSTOWN,CO,80534
Contact Phone# 303-570-6256
Information above has been Verified in Accela by employee noted below
XStkiea. -n 5l/Na'4 April 24, 2008
Processed by: Date
Report ID: EHS00024v003 Page 1 of 1
Print Date-Time: 4/24/2008 2:29:54PM
• WELD COUNTY DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT
1555 NORTH 17TH AVENUE
GREELEY,CO 80631
PHONE (970)304-6415 FAX(970)304-6411 Finaled
•
Permit#: SP-0600051 Sec/Twn/Rng: 13-01-65 Status: ISSUED
Owner: AJ FINANCE Applied: 02/21/2006
Applicant: FINNICK JAMIE Issued: 03/03400k
Permit Type: RNEW C=Commercial,R=Residential+NEW,REPair,VauLT Finaled: -1 (9 Q
Parcel#: 1473-13-1-00-041
Location: 23934 WCR 10
Legal Description:
• Installer: �A 1y li n ei 51j C,
Description: MODULAR
Commercial: N Residential:Y Acres: 5
#of Persons: 4 Basement Plumbing: N
#of Bedrooms: 3 Bathrooms-Full: 3 3/4: 0 1/2: 0
Water Public: N Water Source:
Water Private: Y Cistern: N Well: Y Well Permit#: 256952
Percolation Rate: 94.9 Limiting Zone: 0 ft 0 in Description: CLAY
% Ground Slope: 0 Dir: Soil Suitable: (Y/N) N
Engineer Design Required: (Y/N) Y In 100 Year Flood Plain: (Y/N) N
Minimum Installation Chambers*
Septic Tank: 1000 gallons Absorption Trench: 0 square feet
or Absorption Bed: 3456 square feet
Actual Installation
Septic'Tank: I coo gallons Absorption Trench: square feet
Absorption Bed: 4'5Dc) square feet
Design Type: auLeo ABS/cC Chamber Model
NOTICE
The issuance of this permit does not imply compliance with other state,county or local regulatory or building requirements,nor shall it
act to certify that the subject system will operate in compliance with applicable state,county and local regulations adopted persuant to
Article 10,Title 25,CRS as amended,except for the purpose of establishing final approval of installed system for issuance of a local
occupancy permit persuant to CRS 1973 25-10-111 (2).
This permit is non transferable and non refundable. 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 continuing basis. Final permit approval was
contingent upon the final inspection of the completed system by the Weld County Department of Public Health and Environment.
Enviro ntal Health Specialist Date
Form:S_FINAL
934134
3 75,
io
N.
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0
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cornt
Z5�D��o
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•
:N +,y , •���' High Plains Engineering PAN
735 Denver Avenue • Fort Lupton CO 80621 1"'
Phone 303-857-8280 • Fax 303-857.8238
April 12, 2006
RECEIVED
•
New Vision Homes APR 1 4 2006
Attn: Jamie Finnick
10300 Frontage Road ElfebalLNIAL IMAM SERVICES
Longmont, CO 80504
Fax 303-772-1613
RE: Septic design addendum and septic observation for the proposed home at 23934
WCR 10,Weld County, CO
Job#04-4068
•
'To Whom It May Concern: •
The subject septic design was prepared for a four bedroom single family home. The
. owners have decided to construct a three bedroom home. The E.T. septic design shall
be constructed as follows:
A 1000 gallon two compartment septic tank is required. Two E.T. septic beds 27' x 64'
are required with 3 rows of 9 high capacity infiltrators (H10H)in each bed.
The observation of the septic system at the above-described home site on April 11, 2006
indicated that it was constructed in an adequate manner. A 1250 gallon septic tank was
used. The topography of the site and septic design did not require a lift pump design and
high water alarm.
Sincerely,
,rqO RF /
'p
S48—p 1'
Todd M. Schroeder, P • 8 g/���1
HPE#4
•
• • WELD COUNTY DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT
1555 NORTH 17TH AVENUE
GREELEY,COLORADO 80631
PHONE(970)304-6415 FAX(970)304-6411
Permit#: SP-0600051 Secl wn/Rng: 13-01-65 PERMIT
Owner: AJ FINANCE Applied:02/21/2006
Applicant: FINNICK JAMIE
Permit Type: KNEW O-Commercial,R=Residential + NEW,REPair,VauLT
Parcel#: 1473-13-1-00-041
Location: 23934 WCR 10
Legal Desc:
Description: MODULAR
Commercial: N Residential:Y Acres: 5
#of Persons: Basement Plumbing: N
#of Bedroom . 3 :athrooms -Full: 3 3/4: 0 1/2: 0
Water Public: ` Water Source:
Water Private: Y Cistern: N : Y Well Permit Number: 256952
Percolation Rate trig( Limiting Zone () ft () in Description
%Ground Slope r Direction Soil Suitable(Y
Engineer Design Required(Y/N) In 100 Year Flood Plain(Y/N) h0
From the application Informadon supplied and the on-slte soil percolation date the following minimum Installation spedflatloonssarree required:
Septic Tank \DaD gallons, Absorption Trench sq ft or Absorption Bed �r sq ft
Chambers:Infiltrator or Hancor Standard or Hi-Capacity,EQ36 or BioDiffuser Trench_\ Bed
Infiltrator Quick4 Trench \ Bed
Hancor Narrow(15in)Envirochamber Trench Bed
In addition, this permit is subj t tp the following additional terms and coil Mons:
°fit (�.(:fll�tv�, ; d� daa.�• itutsetin-S� 40
I d
4n¢ KStato_ U
NOTICE
This permit is granted temporarily to allow construction to commence. This permit may be revoked or suspended by the Weld County
Department of Public Health and Environment for reasons set forth in the Weld County 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. This hermit Is non transferable and non refundable. 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 continuing basis. Final permit approval is con ' t upon the final ' tion of the completed system by the Weld
County Department of Public Health and Environment 1 31
(r
Force S PERMITN Environmental Health Specialist Date
WELD•COUNTY DEPARTMENT OF PUBLIC HEALTH&ENVIRONMENT
1555 NORTH 17TH AVENUE, GREELEY,CO 80631 PHONE: (970) 304-6415 FAX: (970)304-6411
WEBSITE: WWW.CO.WELD.CO.US
APPLICATION/RECEIPT
•
Initials: SG
Permit Number: SP-0600051 Receipt Number: HAP-06053
02-21-2006 Amount: $470.00 Payment Method: Check Notation: 14723
Owner Name: AJ FINANCE
Applicant Name: FINNICK JAMIE
Parcel Number: 147313100041
Location: 23934 WCR 10
Account Code Description Amount
2560-41400-4221-4203 New Septic Permit $470.00
256041400-42214203 Repair Septic Permit $0.00
2560-41400-4221-4203 Vault Permit $0.00
2560-414004221-4203 Variance Request $0.00
Description: MODULAR
Commercial: (Y/N) N Residential: (Y/N) Y Acres: 5
Number of Persons: 4 Basement Plumbing: (Y/N) N
Number of Bedrooms: 3 Bathrooms: Full - 3 3/4: 0 1/2: 0
Water Public: (Y/N) N Water Supply:
Water Private: (Y/N) Y Cistern: (Y/N)N Well: (Y/N) Y Well Permit Number: 256952
A permit fee,as set by separate ordinance of the Board of Weld County Commissioners,shall be required of applicants for new individual sewage
disposal systems(ISDS),payable at time of application.permit fees are nortraftmdada:permit appllcatlane are nos transfsrablg,,If both a
building permit and an ISDS are issued for the same property and construction is not commenced prior to the expiration date of the building permit,
the ISDS permit shall expire at the same time as the building permit If an ISDS permit is issued for a property that does not require a building
permit,the ISDS permit shall expire one year after its issuance if construction on the septic system has not commenced. Any change in plans or
specifications after the permit has been issued invalidates the permit unless approval is secured from the Health Officer or his/her designated agent.
Expired permits can be renewed by payment of the permit fee only if:
A.There has been no change in the plans and specifications of the proposed system as set out in the original application or such change is reviewed
and approved by a Division Representative.
B.The surrounding land,its use or zoning has not changed so-as-to cause the original application not to be acceptable under these regulations.
fiCifigg
The completeness of this application is conditional upon further mandatry and additional tests and reports as may be required by the Weld County
Department of Public Health and Environment(WCDPHE).The issuance of the permit is subject to such terns and conditions as deemed necessary
to insure compliance with rules and regulations adopted under article 10 title 25,CRS as amended.The applicant certifies that the proposed system
will not be located within 400 feet of a community sewage system.The undersigned certifies that all statements made,information and reports
submitted herewith are,or will be,represented to be true and correct to the best of his/her knowledge and are designed to be relied on by the
WCDPHE for evaluation for purposes of issuing the permit applied for herein.Applicant further understands that falsification or misrepresentation
may result in the denial of the application or revocation of any permit granted,and in legal action of perjury as provided by law.
X er/App leant a
(; er/Applicant a
Farm RT HAPP
sil se OLa..ct61
-littfatii:3 . .
SEPTIC INFORMATION FORM iq
11 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
O pay the application fee. Ae"repair" fee shall be charged for the expansion,
replacement, or repair of an existing system. The following information must be
,r �RADO provided on the septic information form.
PARCEL NO.: /1/7-1 - TS- / ^ 00 - 041/ (12 DIGIT NUMBER)
CAN BE OBTAINED FROM THE ASSESSOR'S OFFICE AT(970)353-3845 EXT 3650
APPLICANT NAME: _ .C4 nn,CES Ckt evta. Rh,.,i CAC
MAILING ADDRESS: AO ..SOX S2 crreavaineda ST CO ZIP SO-5-3 4
HOME PHONE: (903) 5-10-4
2.-5c WORK PHONE (30 3) 7 7R 3'0918 FAX (30 ) 770-JO i S
PROPERTY OWNER: -.4 , 54/4 /CtS
MAILING ADDRESS: PD.3cx CZ- CITY(ssysnht.4ST Co ZIP gong
HOME PHONE: (303)S 7- 6 z cs WORK PHONE (3&) 772 -0722 FAX (303) 772-It is
lel t3 deS•37/S es 2. E2 /A/ GSA)
LEGAL DESCRIPTION PT PT SEC TWN RNG ACRES
SUBDIVISION LOT BLOCK FILING
DESCRIPTION OF BUILDING(EX; HOUSE,MOBILE HOME,MODULAR,SHOP,OFFICE) A4 DD/JLi'PIC
SITE ADDRESS X23 ?34 LtJC4 * 10
DIRECTIONS TO SITE COP-416t. or CJG4 49 -r' lJC4 /O Oar Die /IcJ So.cJ
COMMERCIAL PERMIT RES ID ENTIAL PERMIT
NEW or REPAIR $600.00 o' + .r REPAIR $470.00
VAULT PERMIT , MINOR REPAIR PERMIT $100.00
NEW or REPAIR $150.00 What is being repaired?
IF OBTAINING A REPAIR PERMIT, PLEASE LIST PREVIOUS OWNERS OF THE PROPERTY:
FLOOD PLAIN YES / NO CENSUS TRACT 25. O 2.
NUMBER OF PERSONS ` i BASEMENT PLUMBING _MUG
NUMBER OF BEDROOMS 3 BATHROOMS: FULL 3 % %z
WATER SUPPLY: PUBLIC YES /} NAME Nat
PRIVATE C)/NO CISTERN Sla WELL NO WELL PERMIT # 25-4.
PERC HOLES MARKED FOR INSPECTION BY SPECIALIST YES/NO 5104400 43 9
03/02/2008 THU 14:43 FAX 303 8 ENGINEERING Ili 002/002
•' Igli Plains Engineering tit
7 738 OewrAvenue• Feet Lupton 6050621
Phone 303.867-0280 • Fax 3004679208
March 2, 2006 pa too s
NAttn:
VisioJamie
Homes i $ r'11Rt
Attu: Jamie
10300 Frontage Road
Longmont, CO
C 80504
Fax 303-772-1613
RE Septic design addendum for the proposed home at 23934 WCR 10,
Weld County, CO
Job# 04-4068
To Whom It May Concern:
The Subject seplie design was prepared for a four bedroom single family
home. The owners have decided to construct a three bedroom home,
The ET. septic design shall be constructed as follows:
A 1000 gallon two compartnient septic tank is required. Two E.T. septic
beds 27' x 64' are required with 3 rows of 9 high capacity Infiltrators(H 10H)
in each bed. }i n /1n.
Sincerely, y '' l ikl/ ""
• y3 z',;
a..r • - ;,3: 8 C•
Todd M. Schroeder, PE : t o
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