2019-06-06_PERMIT FILE - M2019032

• Permit No: M2019032
• IBM Index Class Name: PERMIT FILE
• Doc Date: 6/6/2019
• Doc Name: Application
• From: Castle Rock Construction Company
• To: DRMS
• Email Name: JPL
• Email Name: MAC
• Media Type: D
• Archive: No

I
.COLQRADO DIVISION OF WATER RESOURCES Office Use Only Form Gw 00
DEPARTMENT OF NATURAL RESOURCES
1313 SHERMAN ST.,RM 818,DENVER,CO 80203
phone—info:[phone] main:[phone]
fax: [phone] htt ://fiwvw.water.state.co.us FEB 17 201
RESIDENTIAL Note:Also use this form tospply for fivestockwatwing WATER RESOURC S
Water Well Permit Application srgT COLOINEE
Review form Instructions prior to completing form.
The form must be completed In black or blue ink or typed.
1.Applicant Information S. Use Of Well check applicable boxes
Name of applicant See instructions to determine use(s)for which you may qualify
1 rYI i f h y ��i� ❑ A. Ono ouy h �j Id use In one single-family dwelling
Marling address q -
55_-3 5 Sd licit-fy RcAd lit IS B. Ordinary household use in 1 to 3 single-%miy dwellings:
city —r swia Zip _ Number of dwellings: 1
"lY`r•ik1CL yo gd f,cl ® Home garden/lawn irrigation,not to exceed one acre:
Telephone* E-mail(optional) area irrigated ❑ sq.ft.9 acre
(71 F) 76 V-3y.2 9 ® Domestic animal watering—(non-commercian
2.Type Of Application (check applicable boxes)
■Construct new well [I Change source(aquifer) ccC. Livestock watering(on farm/ranch/range/pasture)
[:1 Replace existing Well ❑Reapplication(expired permit) 7•Well Data(proposed)
❑Use existing well ❑Rooftop precip.collection Mandmum pumping rate Annual amount to be withdrawn
❑Changeor increase use ❑Other. %S gPrT1 J acre feet
3. Refer To(if applicable) Total depth nV feet Aquifer (� r. I�rz ci
Wen permit tt Water Court case ti
8.Water Supplier
Designated Basin Determination# well name or M Is this parcel within boundaries of a water service area?❑YES X NO
If yes,provide name of supplier:
4. Location Of Proposed Well Im ortantl See Instructions).. 9.Type Of Sewage System
- -------------------- -
L;rt Co/n (J _ 1/4 of the -5 CSJ 114 ® Septic tank/absorption leach field
Section —Township N or S Range E or W�Principal Meridian ❑ Central system:District name:
/d _._._1___17 ❑® 5:� ❑X E El Vault:Location sewage to be hauled to:
Distance of well from section lines(section liras are typically not property lines)
Ft.from❑N❑S Fe from❑E O W I ❑ Other(attach copy of engineering design and report)
For repla�amern,ieils�rY- stan�eai;d' i«%nmad wall to raw wall
10.Proposed Well Driller License#o tional : 5
f-t direr;ion, 1 i.Signature Of Applicants)O r AUtiiored Agent '
Wall location address(Include City,State,Zip) Check if well address is some as in Item 1.
The making of false statements herein constitutes perjury in the second
. degree,which is punishable as a class 1 misdemeanor pursuant to C.R.S.
24-4-104(13)(a). I have read the statements herein,know the contents
Optional. GPS waft location Information In UTM form GPS unn settinpa we as fellows: thereof and state that they are true to my knowledge.
Format must be UTM sign two ba erthaM ) Dates
❑Zone 12 or fly Zone 13 Easting: / / /O
Units must be Meters
Datum mutt be 11AD43 Northing: �,1^s title ,// /,,
Unit must be set to true north V , At Stl 17V1 ,/a I" 0 W n e r—
Was GPS unit checked for above? ®YES I Remember to set Datum to NAD83 Office iC@ Use Only
S. Parcel On Which Well Will Be Located USGS map name IrMR map no. Surface elev.
_SYOU MUST ATTACH A CURRENT DEED FOR THE SU13JECT PARCEL
A.You must check and complete one of the following: Receipt area only —�
❑ Subdivision:Name
Lot Block Fiiirngiunit
❑ County exemption(attach copy of county approval&survey):
Name%It Lots Trans Number:3644532
2117/201012:22:54 PM
❑ Parcel less than 35 acres,not in a subdivision,attach a deed with metes Debble Gonzales(20)
and bounds description recorded prior to June 1,1972,and a current Total Trans Amt:$100.00
deed CHECK
❑ Mining claim(attach a copy of the deed or survey):Name/# PV Check Number: 3224
J$ Square 40 acre parcel as described in Item 4 WE 7 Check Amount' $100.00
❑ Parcel of 35 or more acres(attach a metes and bounds description or survey) WR _/
❑ Other(attach metes&bounds description or survey and supporting documents) �/,/
B.*of acres in parch n C.Are you the owner of this parcel? CWCB V
D BYES MYES ❑NO(d no—see instructions) TOPO
D.Will thus be the only well on this parcel? BYES ❑NO(it no—list other wails)
MYLAR sas DIV V R WD,19 BA ) MD
E. state Parcei I oral