2017-04-05_PERMIT FILE - C1982057 ‎(10)‎

• Permit No: C1982057
• IBM Index Class Name: Permit File
• Doc Date: 4/5/2017
• Doc Name: Permanent Pond Demonstrations
• Section_Exhibit Name: Tab 20 Attachment 20-2 Appendix 20-2.2
• Media Type: D
• Archive: No

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DIVISION OF WATER RESOURCES
303 - 866 -3581
FOR OFFICE USE ONLY
DAM NAME NO. WATER DIV: DIST:
NOTICE OF INTENT TO CONSTRUCT A NON - JURISDICTIONAL
WATER IMPOUNDMENT STRUCTURE'
This notice is required per Section 37 -87 -125, C.R S. (1998)
This notice must be submitted to the Division Engineer's Office a minimum of 45 days prior to construction.
(PLEASE PRINT OR TYPE NOTICE)
OWNER INFORMATION
Name: ` t: r�r<<_u Lt <e L �t ►���:
Address-
Street / P.O. Box/ Rural Route
Telephone- ( ) 7 , ) ?- 72 =y' )'7
Cl
State
Zip Code
Responsible Person: Telephone
Address-
Contractor:
Street / P.O. Box/ Rural Route
STRUCTURE INFORMATION
State
Telephone:
Name of Dam. i Water Division
Location 2: J�
• Option 1 /
OR
.Option 2—►
Zip Code
Water District.
'/4 /' /4 Sect: '/a of the %a; Sect: , Township: , Range: P.M.
Distance of dam from Section lines ft from UN D S, ft from DE OW
Utilizing GPS: Set to UTM Datum. Measured on crest of dam above streamline /outlet.
Northing y41 7,V !Vl S. 6 m. Easting 310 SbL
Note: GPS settings must be NAD83 CONUS.
Dam Dimensions: Vertical Height 3: Length; ft., Slopes: U /S:L H:1V, D /S H 1V
Reservoir: Surface Area 1: ) , -f acres, Capacity 1: j 1, 5 acre feet, Drainage Area: acres
Emergency Spillway: Width: ) S ft., Side Slopes: ;2,+--:3 HAV, Freeboard 4:
Outlet Drain: Type: - r_,cr? r'_c >t.,� :i;�,) %z:�:jSize: je-' inches, Location: ej-
Stream Name or Water Source 5: C 1 4
Proposed Water Use: 4 it;, e < k 1 1" ,1�1 � � } � Water Court Case No. (If applicable)
7
Signature of Owner Date
DIVISION ENGINEER'S REQUIREMENTS: A Lo\Ar- tGvr=( e"-rI ET njirr Aj g�S ap 3yRASS2.,)6 At(
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DWR (03/07)
Signature of Division Engineer Date
A "Non - Jurisdictional Structure" is a dam creating a reservoir with a capacity of 100 acre -feet or less and a surface area of 20 acres or less and a vertical height (see
footnote 3) of 10 feet or less
2 Please see example on reverse side (or page 2) of this form
3 "Vertical Height" is measured from the elevation of the lowest point of the natural surface of the ground where that point occurs along the longitudinal centerline of the dam
up to the crest of the emergency spillway of the dam
4 "Freeboard" is the vertical distance from the bottom of spillway to the crest of the dam
51f construction in reservoir intercepts groundwater, a well permit is required (Well permit applications can be found at www water state cc us /pubs /forms asp) f4T( .
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