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I jl <br /> COLORADO DMSION OF WATER RESOURCES 0M 6 Use only Fo GWS 44(os2oo6) <br /> DEPARTMENT OF NATURAL.RESOURCES <br /> 1313 SHERMAN ST_, RM 818, DELVER,CO 80203 <br /> phone-info:(303)866-3587 main:(303)86fr3581 <br /> fax 333 866-35B9 http;/Avww.water.staMco.us <br /> RESIDENTIAL Noce:A:sn use utis lam,to apply for thcesioeh watering <br /> Water Well Permit Application o.00 <br /> Review instructions on reverse side prior to completing form. Zt "D::3 3.d1S <br /> The form must be completed to black or blue ink or typed. $�^` 'S-],d}I1tfiN <br /> 1.Apticarrt Information , _ _ 6.Use_Of Well �edc applicable box nr <br /> tr na ro aPPIG]M _ __- See instructions to determine use(s)For which you may quality <br /> ❑ A.Ordinary household use in one single-family dwelling <br /> outside � f13� a <br /> t*]3 u S B.Ordinary household use in 1 to 3 sin O `` \ gtafamity dweumgs: <br /> F � _ Number of dweIIings: l <br /> ZIP,coon. <br /> ;0 lieste gardenAewn hrigation,not to exceed one acre: <br /> l elophone lr Q u E-boat Intl -4 area irtigatad Elsq.ft.❑ tx ae <br /> 2.Type OfApplitt:ation( eck applicable boxes) !❑t7onlBst,cartimalwalering-(non-ogmmercEa� <br /> C.ILivesio <br /> 41 Construct new wen []Use existing well <br /> ❑ dc watering(err fertrdrarrldrlrartge/pasture) <br /> ❑Replace existing wen p change or Increase use T.Well Data(proposed) <br /> Q Charxle source(aquiler) [i Reapp6carion(expired permit) ►1oxYnum p jmyng rare --- pq oral artgntro be wttasrawn -- <br /> Other. gp- acre-feet <br /> 3. Refer To(d applicable) To1a1dopn Aq,der <br /> Wail xnnl Y Wit-Cant qa,e A—�._..�—�_ ) S V rent ,j toll <br /> 8.Witer Supplier <br /> oestgnatee Basin txknnvrat on Is this parcel within boundaries of a water service area?QYEs®No <br /> B yes,provide name of supper <br /> 4. Location Of Proposed Weft _ 9.Type Of Sewage System <br /> - <br /> 1111 vA�,t,a tK Septic tank 1 absorption leach field <br /> rowrt• ' N or s Range E Q W I Prn14r1:Mend an <br /> -�� p� Central system:District name: <br /> �D__ 0 r_1�❑�_ _____ ❑ V.LR:LocaUon sewage to be hauled 1a <br /> kU,nco d wen%omaeceon rues{section rrnrs me typic"not property snos) i <br /> Fr.mom[]N❑S Ft.from 0 E D W ❑ Outer(attach copy of engineering design and report) <br /> For iepi o—.t weft any-6z.,rce and dk=am Aom Wd wen to new Wes _ 10.Pko osed Well Driller License tiona l : /y <br /> feet directlon 11.Skgnatur,e Of Appllca_nt(s)Or Authortzed Agent <br /> War Ixation oddrese{Inetudo Ctty,Stab.Ap) Cva d wet addmw b samr.as in ttetn t_ ' <br /> Them king of false statements herein constittIIes perjury in the second <br /> degrees,which is punishable as a class 1 misdemeanor pursuant to C.R.S. <br /> 244-104(13)(a). I have read the staterrxm s herein,know the contents <br /> Optorrar: GPS Me:I bC:*M tiouWl on in JTtA ramaL CPS and 9enmys am as tdbws - there- -- State that they are true tD owledge.____ _ <br /> -. _ Sgn ( be PVrgi si rnatlsel Dalo <br /> FpT1A t muV t",Ulu <br /> El Zorn 12 or 9 Zom 13 EasUrtg U3!J /ants �/ <br /> mr,9r bo IAainr'a y3, <br /> D 3 /�S <br /> +mm me9t be kltOa3 �. NnAhinjL <br /> LAntmu1 besetrobr no r <br /> Was GPs,�dwcked for above, jo vM Relmmeer to set Datum to tl AE= Off ce Use Only _ <br /> 5. Parcel On Which Well Will Be Located ItSC,S m 1p name --'T - oinRmap no surface ate.. <br /> PLEASE ATTACH A CURRENT DEED FOR THE SUBJECT PARCEL) <br /> nyetefollowing: <br /> ^ � I <br /> A_You must check and co - -" �" —---- <br /> PI one of the followi n9= ^ Receipt area only <br /> ❑ Subdivision:Name O <br /> Lot /3 Block^� Fllinglurd �j� <br /> ❑ County exemption(attach copy of county approval&survey): , l (`�s <br /> Names Lot C Tarns Number:3646375 <br /> * Parcel less than 35 acres,not In a subdivision,attach a deed with metes � I 7/1320101:17:32 PM <br /> and bounds description recorded prior to June 1.1972.and a current ee oGo�e(0) <br /> dead TotlTFa ng <br /> CHECK <br /> I L <br /> ❑ Mining daim talracn a ooproi tre deed or�L NameJ# — $LTt iVUri b 1891 - <br /> �] Square 40 acre parcel as described In Item 4 wF Check Amount: $100,00 <br /> 19 Parcel of 35 or more acres(anann a:mms and bounds aecatptlon arsmey) WR v i <br /> ❑ Other(abdr metes&bawd.aesa"on er away and eapportm doannerusi cwce <br /> 13 it nr vacs:n parcel C.Ara roe ma owner of tb�pared? <br /> AYES❑NO 4r no-9m Iratrucbm TOPO <br /> D.Wit in*be the�r "'0 Vn.n�pwceO oYl--s [I ro(nno-W;otrW;�s) — LMAR 2 u <br /> SOS DIV— WD— BA-- MD <br /> E. State Paroef in► iano' <br /> I <br /> E'd 99LZZ9Z0L6 l N011]!HS : (OP e7C:Fn ni of tirr, <br />