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Please return this to Dale and Ellen Schmidt with any changes: <br /> Site Address: 425 River Run Drive <br /> Site Owner: Sue Smith Moak <br /> Site Owner Mailing Address: 425 River Run Drive, Pagosa Springs, CO 81147 <br /> The following structures are located on or within 200 feet of the affected area (the Schmidt Site): <br /> 1 Fence (jointly owned, located on Schmidt Site) <br /> 2 Outbuildings (at 200 feet +/-from Schmidt Site) <br /> 3 Well and pipe (approximately 200 feet +/-from Schmidt Site) <br /> 4 <br /> 5 <br /> The following notes and requirements should be included in the agreement: <br /> 1 No other known structures within 200 feet <br /> 2 <br /> 3 <br /> 4 <br /> 5 <br /> The following additional information is needed by the property owner before signing the <br /> agreement: (please add as necessary) <br /> 1. <br /> 2. <br /> 3. <br /> 4. <br /> 5. <br /> DATE: <br />