2015-08-11_PERMIT FILE - C1992080 ‎(2)‎

• Permit No: C1992080
• IBM Index Class Name: Permit File
• Doc Date: 8/11/2015
• Doc Name: Well Information Abridged Permit
• Section_Exhibit Name: Appendix 5-13
• Media Type: D
• Archive: No

COLORADO DIVISION OF WATER RESOURCES
Office Use Only Form GWS -44 (7/2012)
DEPARTMENT OF NATURAL RESOURCES
1313 SHERMAN ST., Ste 821, DENVER, CO 80203
Main: [phone] Fax: [phone] dwr ermitsonline state.co.us
RESIDENTIAL Note: Also use this form to apply for livestock watering
Water Well Permit Application
Review form instructions prior to completing form.
Hand completed forms must be completed in black or blue ink or typed.
1. Applicant Information
Names)
6. Use Of Well (check applicable boxes) _
�AK�1��it~yY/ Cyt"
See instructions to determine use(s) for which you may qualify
❑ A. Ordinary household use in one single-family dwelling
Mailing address
(no outside use)
4b t 3 F- JACM0 R,GIRW AcT�/
B. Ordinary household use in 1 to 3 single-family dwellings:
Code
city � F�LIVS state�-' � `
Number of dwellings: 113
Telephone (w1area code) - E -ma' il/y` —
Home garden lawn irrigation, not to exceed one acre:
94-0 302. 4474
area irrigated sq. ft. X acre
2. Type Of Application (check applicable boxes)
N' Domestic animal watering - (non-commercial)
❑ Construct new well ❑ Change source (aquifer)
C. Livestock watering (on farm/ranch/range/pasture)
❑ Replace existing well ;9 Reapplication (expired permit)
Use existing well ❑ Rooftop precip. collection
7. Well Data (proposed)
Change or increase use ❑ Other:
Mapmum pumping rate Annual amount to bewithdrawn
3. Refer To (If applicable)
I'5� gpm uNW4&W ►�
permit # — ' Water cast rase # --
WeBa
ZM
Total depth Agwfer
few ti141Z1J>�..� AOfd t�fldlJ
Designated Basin Dalian, :nation # walname or#
(AKA -4
8. Water Supplier
PW 1 SZ
Is this parcel within boundaries of a vrater service area?l=1 YESA NO
4. Location Of Proposed Well (Important! See Instructions)
If yes, provide name of supplier.
°oanh
LA PLhTot se 1/4 of the `> 114
9. Type Of Sewage System
-
,- _
sectionTownship N ors mange a of W Principal Medan,
❑Septic tank /absorption leach field
3�' 34 -as Iix (- 9 Q J1 t49W WIIKIW
❑ Central system: District name:
Distance of well immsection lines (section rkmwe typically not pmpenylines)
❑ Vault: Location sewage to be hauled to:
111FO Ft from I` N ;KS 1200 FL from gE I_ W
For replacement wells orgy -dstanceand ckedicntianddwelltonew well -
❑ Other (explain)
feet_ Direction
10. Proposed Well Driller License #(optional):
Weil location address (Inciude city, state, Zip) [1 -check if well address is same as in Item 1.
11, Sign or Enter Name of Applicant(s) or Authorized Agent
o q-lD a A4T"OvIzAt GO LAT
J �
eme -- -- e
The making of false statements herein constitutes perjury in the second
LA PLATT Cov" C�
degree, which is punishable as a class 1 misdemeanor pursuant to C.R.S.
-� " -- _ll -
Optional: GPs well location infomtation in IJTAA fomret GPs unit settings are as follows:
24-4-104
24-4-104 (13)(a). I have read the statements herein, know the contents
and state that they are true to my knowledge.
Forma[ must be UTM
Zone 12 or " Zone 13 Fasting:
Units must be Meters
--or-- persons) 'ttincJ-8wication._. - Date (mmlddiyyyy)
C
-=Prin,
Northing:
Datum must be NAD83
Unit must be set to we north Remember to set Datum to NAD83
titre
Was GPS unit checked for above? ❑ YES
{`
5. Parcel On Which Well Will Be Located
Office Use Onl y
ou must attach a current deed for the su 'ect I cel
— —__-- -----_—_.. � Pa )
- - - - - ----- --- -- -
USGS map name DWR map no. surface dev.
A. You must check and complete one of the following:
30 Subdivision: Name CAW 2AnGE N("'���Q
Receipt area only
Lot 2 Block Fling/Unit
❑ County exemption (attach copy of county approval & survey)
Name/# Lot #
❑ Parcel less than 35 acres, not in a subdivision attach a deed with metes
& bounds description recorded prior to June 1, 1972, and current deed
❑ Mining claim (attach copy of deed or survey) Name/#:
❑ Square 40 acre parcel as described in Item 4
19 Parcel of 35 or more acres (attach metes & bounds description or survey)
AQUAMAP
❑ Other: (attach metes & bounds description or survey)
WE
B. # of acres in parcel C. Are you the owner of this parcel?
3s7•490 g YES 1=I No
WR
D. Will this be the only well on this parcel? ;V YF_SUI NO Gr no - list other wells)
CWCB
TOPO
___._._. ----. -------------_...
E. State Pard los (opoonal):
MYLAR
S65 DIV WD BA MD