Laserfiche WebLink
r � <br /> !. COLORADO DIVISION OF WATER RESOURCES For Office Use Only I <br /> Form No. I DEPARTMENT OF NATURAL RESOURCES <br /> GWS-11 1313 Sherman St., Ste 821, Denver CO 80203 <br /> 0812016 (303)866-3581 <br /> _: dwrpermitsonline(astat_e.eo.us _ _� <br /> CHANGE IN OWNER NAMEIMAILING ADDRESS <br /> PRIOR TO COMPLETING THIS FORM,SEE INSTRUCTIONS ON REVERSE SIDE ` <br /> INCOMPLETE,POOR QUALITY,OR ILLEGIBLE FORMS CANNOT BE PROCESSED AND WILL BE RETURNED RECEIVED <br /> Name,address and phone number of person claiming ownership of the wellpermit: <br /> Name(s): JAMES GREGORY SINDAD and CYNTHIA LYNNE TAMMARO i AUG 2 9 2019 <br /> i <br /> ` Mailing Address. <br /> t/ C�G D 15 fl WATER <br /> STATE ENI :ER RESOURCES <br /> City, St. Zip: ( COL© <br /> /t'f Qll¢ff — — 6/ <br /> Phone ( } r�. /6 Emad: t� flt/✓i`tTJ C�/" f��L �� i <br /> Well Permit Number.249009 Receipt Number:0507230A Case Number(optional): <br /> WELL LOCATION: County: LA PLATA Well Name or# (optional): <br /> Street Address at Well Location City State Zip <br /> ❑Check if well address is same as owner's mailing address <br /> SW 1/4 of the SW 114, Sec. 21—_ ,Township 35.0 0 N.or0 S., Range 1 1,0 ❑E.or©W. N.M. P.M. <br /> Distance from Section Lines 700 Ft.from❑N. or Q S. Line, 350 Ft.from Q E.or ■-I W.Line. <br /> Subdivision Name (if applicable): HIDDEN RIDGE RANCH Lot 3 Block , FilinglUnit <br /> NOTE: If changingrcorrecting the permitted location of a well, use Form No. GWS-42. _ <br /> I (we)Claim and say that t am(we are) the owner(s)of the well permit described above, know the contents of the statements made herein, <br /> and state that they are true to my(our)knowledge. This filing is made pursuant to C.R.S. 37-90-143. { <br /> Signatur s)of the New Owner _ _Please print the Signer's Name&Title i Date I <br /> It is the responsibility of the new owner of this well permit to complete and sign this form. If an agent is signing or entering information, please <br /> see instructions. i <br /> Please allow 4 to 6 weeks for processing of this form. Thereafter,you can view or print the accepted document at: i <br /> htt .11www.dr,r state.co.usANellPermitSearch <br /> Signature of DWR staff indicates acceptance as a Change in Owner Name and/or Mailing Address. <br /> For Staff Use Only <br /> j I <br /> Dat���.... <br /> Staff Signature <br />