2016-11-04_PERMIT FILE - M2016009 (7)

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'J COLORADO DIVISION OF WATER RESOURCES Office Use Only Form GWS-44(1/2001) DEPA,RTMEN.OF NATURAL RESOURCES CE`vE� RECEIVED 1313 SHERMAN ST.,-RM-818,.DENVER,CO 802 /1 RECEtVEO -hone-info-(303)866-3587 main:(303)866-3581 (303)866-3589 http://www.water.state-co.us APR 0 9 2003 RESIDENTIAL Note:A1=o use this form to apply M toctc Ovate MAR 0 3 2003 Water Well Permit Application ur►+�o-;T6 ►► w 1AIE Review instructions on reverse side prior to completirl ft. I CaO. v...,001,50uRERS The form must be completed in black ink STATE o. 1. Applicant Information 6. Use Of Well.(check a licable boxes) Name of item See instructions to determine use(s)for which you may qualify ee ❑ A. Ordinary household use in one single-family dwelling Mailing address Ino outside use) D �O� / (� B. Ordinary household use in 1 to 3 single-family dwellings: cky stet La toes Number of dwellings: Telephone Y Home garden/tawn irrigation,not to exceed one acre: ( 21!2 ) _ area irrigated ❑ sq.ft.❑acre 2.Type Of Application (check applicable boxes) Domestic animal watering-(non-commercial) 19 Construct new weu ❑Use existing well C. Livestock watering(on farm/ranchlrange/pasture) ❑Replace existing well ❑Change or increase use ❑Change source faquifer) ❑Reapplication(expired permit) 7. Well Data (proposed) ElOther: Maximum pumping rat Annual amount to be withdrawn 3. Refer To (if applicable) Total depth m Aw11er acre-feet wen permit# wow court as a feet 8. Water Supplier Designated assin Determination# Well name or/ Is this parcel within boundaries of a water service area? YES NO It yes,provide name of supplier: 4. Location Of Proposed Well 9. Type Of Sewage System ry p Ve b t t fa or>M _va Septic tank/absorption leach field section Township N or S Range E or W I Principal Meridian ❑ Central system:District name: 3 s' t ❑ ❑ ASo1nce of wall from section es Isectioo Ines are typically not property Ones! ❑ Vault: Location sewage to be hauled to: lin r r2 from'A N❑S ate) Ft.from❑E jQ W ❑ Other(attach copy of engineering design and report) For replacement wens only-distance and direction from old wag to new wet{ feet direction 10. Proposed Well Driller License#(o iional): Well location address of appticabW 11. Signature Of Applicant(s) Or Authorized Agent The making of false statements herein constitutes perjury in the second Opffonsh GPS weu location information in UTM format degree,which is punishable as a class 1 misdemeanor pursuant to Requitred settings for GPS units are as follows: C.R.S.24-4-104(13)(a). I have read the statements herein,know the Format must be UTM contents thereof and state that they are true to my knowledge. Zone must beta Northing Sign here at be evynrdsignature) Data Units must be Meters a /ill Datum must be NAD27(CONUS) Easting r (/J Prim name 8'" Unk alit be set to true north Were points averaged?❑YES ❑NO 5. Parcel On Which Well Will Be Located Office Use Only _ USGS map name OWR map no. Surfers elev. i A.You must check and complete one of the following: V MC/Gfft1 1 ?D`- ❑ Subdivision:Name Receipt area only Lot Block Filing/Unit - (I-S ace ❑ County exemption(attach copy of county approval&survey): I'o e6 n/tJ Name/# Lot# ❑. Parcel less than 35 acres,not in a subdivision,attach a deed with IOlge y 587252 metes and bounds description recorded prior to June 1, 1972 3/3/28N3 -- 3:33:0 P8 ❑ Mining claim lattach a copy of the dead or survey): Cashier ID: 81 Namel# ' ❑ Square 40 acre parcel as described in Item 4 �)W Check PuTcllase- #2653 Parcel of 35 or more acres{attach a metes and bounds description or survey) i--t WE •� Other lattach metes&bounds description or survey and supporting documents) S.1 of acres in parcel C_Are you the owner of this parcel? WR a YES ❑NO lif no-see instructions) cWCa D.Will this be the only waft on tW parcel? K YES ❑NO tit no-Ost other wells) TOPO V,- `�{ftt-� CfW AtXAr r� E. Stets Parcel IDi;optionaq: MYLAR -( SBti 01v W BA MD