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VP[ <br />{COLORADO DIVWgN OF WATER RESOURCES ! CEIVEO APR 112000 <br />UEPAFITM "OF NATURAL RESOURCES <br />1313 SHERMANST., RM. 818, DENVER CO W203 JUL 2 5 20 INAris;►.r :•�.. :: <br />ptione - info: (303) 868 -3587 main: (303) 866 -3581 blAli I rJ:... i I. <br />tAN U <br />RESIDENTIAL * 1►rrate: you" dso use this inns to apply far &evwat v#&wm) 114*twl lI Permit Application <br />Revlew wa<truafm s miar is emmistints i o v 6a 0"n' lJld isl bine!I[ inSr ar tunnel <br />1. APPLICAi t INFORMATION . <br />S' . USE OF WELL (dmdc approftte om or entries} <br />reamer <br />see Itr huctbw to deterrohn w;*) for Miioh yam. may tpea@fy <br />William Rodman <br />0 A. Ordinary household use In one singie -family dwelling <br />� orrWde l�0) <br />M B. Ordinary household use in 1 to 3 single - family <br />"1i hVA"' <br />3613 F St. <br />dwellings; <br />Number of dwelinga: 1 <br />M Home gardenAawn ielgatton, not to exceed 1 acre: <br />� seas <br />Greeley, CO 80631 <br />y r <br />area Irrigated 5 13 sq. it. M acre <br />13 Domestic an Mal watering - (non- commercial) <br />❑ C. Livestock watering (on famurarecitira asture) <br />r awnenesameer snowdew.e..dre <br />970 --3a1 -0255 <br />2 TYPE OF APPLICATION (ftek siWicsWe bmdes)) <br />❑ Consmat new well E3 Use existing wall <br />7. WELL DATA <br />M Replace exisdne well D .Change ! Increase Use <br />.,niisd onu mi° m d' eidi&0wo <br />O c hwce (mircei aquifer O Reappliczition(.ral:.d panda <br />50 alM 15 a «e tent <br />O Other. <br />ran erem wa„ irw <br />40 teat Alluvium <br />3. REFER TO Of icable): <br />wear *me one: <br />Rem ilt s <br />9. TYPE OF RESID9YTIA(, SEWAGE SYSTEM <br />W -4715 <br />1-- 3597 -F -R <br />0 Septic tank Iabsorption )eachi Seid <br />C3 Central system <br />veftl ) <br />Monhodno hole adw4wledpment ! <br />-VE- <br />MH- <br />District name: <br />17 Vault <br />wee name or # <br />Location sewage to be hauled to: <br />Ca Other tattaeh o of e deli n) <br />4. LOCATION OF V&U <br />county <br />alrertpfQwrtsr nwrter <br />9. PROPOSED WELL DRILLER 1 cnal) " <br />Weld <br />NE y SE Y+ <br />M. <br />R & R Well and Pump <br />uemnaaNaW- <br />857 <br />section <br />Towrma* N or a <br />Ranpt E or W PIkOW raetd- <br />35 <br />6 M C] <br />66 ©10 6 <br />10. SIGNATURE of appficant(s) or authorized agent <br />Diehrlcs of well horn section Ines W'31� <br />The making of false statements herein conatiix,tes perjury <br />1350, iL frare ©N 13 s <br />in the second dWee, which is punishable as a class I mis- <br />demeanor puts not to C.R.S. 24.4- 104(13)(a). 1 have read <br />Web keagw+sdt.n, k dint ne nom sesaow* addres F gw1P W <br />the statements herein, know the contenls thereof and state <br />that they are bxm to my knowled <br />h:, real�earo..,e wain a sy . aMnrsa wi Breeden xem eia YYNI to rnw wee <br />150 fleet S.E. direction <br />siket hr la *W eKnaana <br />• <br />S. TRACT ON WHICH WELL WILL BE LOCAT90 <br />A. Vou most shack alt of to fobwiite - sae kw&uaftro <br />13 Subdvisiorr. Name <br />4 -6 -00 <br />Lot no. Block no. _ Fling/Unit <br />OPTIONAL INFORMATION <br />E3 county exattption (attach copy of county approval & surveA <br />trees "y° naA1e <br />ouvrh e,4 ^" <br />e0e • <br />Name/no. Tract nil <br />17 Mir ttQ claim laetach oopv of deed orswvevl <br />hlalrteMo. <br />Ice Use Only 4i1Piilii '"- J73505 PM <br />✓ Ushier Ill. it <br />[,Ja- N6ISE i DIV <br />10 Other (attach )opal desehiptionto apowation) <br />$ 25.0 <br />5.25+- in the NE 1 / 4 SE 1 , 4 Sec 3 5 T 6 <br />, R6 5W Cbeck Purchase- 01524 CO <br />7r0 a qAe ' <br />r-f.E wrs.c (- e WD <br />94 <br />B. STATE PARCEL <br />ID : <br />C. / ewes in treot <br />D. Are veu the owner of this prole .? <br />5.25 — <br />MYES CI NO Eno- � dotailed inner.) <br />33 � <br />Iii 6 F" 13A <br />gq <br />�-IWYES WIN this be the only well on this tract? <br />❑ NO Of ether wells we on this treat - ens dstalled Inst.) <br />� ^ 0W L - - - MD <br />Form GWS-44 (11195) <br />