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• � � i1 <br /> atoll�o,Mr.KsMI <br /> 11 Nov. 15.2013 06:56 PM Brad and Diane Smith 703 528 4334 PAGE. 1/ 2 <br /> 'I 4 z±!,1- <br /> COLORADO DIVISION OF WATER RESOURCES Office Use Only <br /> ATURAL RESOURCES <br /> 11313ARTMENT SHERMAN ST.,Ste 821,DENVER,CO 80203 RECFIVF[ <br /> Main: 303 OW3581 Fax: 303 f)W2223 d r, i sonline DEe � 8 20 N O V 212013 <br /> RESIDENTIAL Not.Alin use this form to apply lot livestock watering 13 <br /> Water Well Permit Application sr,lication v. ! <br /> STATj�rE RESoUR,� 6t�. <br /> Review form Instructions prior to completing form. C,aNCiNEF`f; <br /> Mond completed forms must be completed In black or blue Ink or typed. ? <br /> 1.Applicant Information L <br /> ._. <br /> _y+•msisl __ .-......_..._.--......... .... .... .—__. ... -- • g•Use Of Well jCheck applicable boxes) <br /> Brad Smith See instructions to determine use(s)for wNch you may quality <br /> ❑ A. Ordinary household we*In one single-family dwelling � <br /> N•Aii+p addr.a .....'"...-- —..__. - .... --- - (no outside use) <br /> 2006 North Hanrortk ■ 8. Ordinary household its&in 1 In 3 ainoIA-family dwellings: <br /> ity I bore Zip woe Number of dwellings: 2 <br /> Arlin ton VA 22201 <br /> 1`eiepnone Iwl•ne.00del E.mea 0 Home garden/lawn Irrigation,not to exceed one acre: <br /> 703 980-6416 Smithb sainc.com area Irrigated ❑aq ft.p acre W <br /> 2.Type Of Application (_check applicable boxes) D Domestic w)mat watering-(non-commercial) (D <br /> Construct n!w welt ❑Change source(tiqulfer) ❑ C. Livestock woteting(on fannlreneh/range/pasture) 0 <br /> ❑Replace existing well ❑Reapplication(expired permit) <br /> ❑use existing well 0 Rooflop predp.collection T.Well Data(proposed) <br /> El Charige or increase use O Other' M.om�m pwnpmp ie a Airur imam Ip a wthdtauen 0 <br /> 3.Refer To(if applicable) _ r w win 9vm Ao�i+�_- 1/3 we-feet 0 <br /> w•u pvt.lt r ..t.werw Court case r . . feet <br /> 160 D <br /> �•alpnatil auv Diaiminaianrr _ wt+ii name or r -- 6.Water suppller <br /> le Ihis part- within boundaries Of a water service aces?Ca YE9® NO 0) <br /> 4.Location Of Proposed Well Im oRantl See Instructions It es,provide name of supplier. <br /> -._.Lo rop _.—i_p.. ._. _.. --- - �.. <br /> 6& y I 8.Type Of Sewage System 0) <br /> Lake 4 _.. -F�— tie of fie NW ire -- -- --- . ..— --....__,..., <br /> sea+on T wntn Nab Rar E a W annacr M•rtAen ■Septic lank/absorption leach Cold <br /> 28 ❑t3 ID 80 Q laf 6th Central system.District name: <br /> I __.... <br /> Dltisnt•o+wei aanaeaonitrra Iweionines sro iypiuiiy frig yopeny ine�i- ❑Vault:Location sewage to be hauled to, <br /> 2440 Ft ivmFN nS 2400 Fi.from❑IE ®W <br /> Fo r1pnN wiaaay-stance arts @racoon from ow well to now wW 0 Other(explain) <br /> feet Direction 10.Proposed Well Driller License p o tional <br /> weri I6eWMn Addr•ei(induce A_y ifs,Zipj Cntci a wan.dorou a same es rn nam/ 11 Sign or Enter Name of Appllc brI or Authorized Agent <br /> 1�42 A County Rd 36, Leadville CO 80461 The making of false statements herein oonetRutes-perjury in the second <br /> {692 Y degree,which IS punishable as a class 1 misdemeanor pursuant to CA.S <br /> 24.4-104(13xa). I have read the statements herein,know the contents <br /> IoaN:Gp6 wei iOUeon rrformtign in UTM famai GPS urot ter a en w blloWt_ _ <br /> ------- - - thereof and state that the are rue to m krtowted e. <br /> roal+w mutt a UTM -__._....... ..._-� ,—_ <br /> C1 Zone 12slip Lone13 3 �) BGnor t)dptrio t u ripeppr con tHN(mMddlyrir) <br /> EatbnO <br /> uMs putt be Mwit 11/15/2013 <br /> DetNAMm meat be NA Nonhinp j L' L l ti l <br /> it tipnlnp pilot name <br /> Unit nrrn Oe eN to to norm N.,nnulwr to aei Detuut to V ADB <br /> Was Gp6urrcaiecad for wove? YES B d Smith.Owner <br /> 5.Parcel On Which Well WIN Be Located Office Use Only <br /> rom m a surrem geed for Vw subject parcel --•- map no - <br /> ....-. .- ) ..- .. USGs map name I Dw.map no swten ecru <br /> AL You must check and complete one of the folloOng: <br /> ❑ Subdivision.Name 3ecL(a & r Lot 2 Block _ FIIIng/Und Receipt area only <br /> ❑ County exemption(attach copy of county approval&survey) <br /> Name/# Lot# <br /> ❑ Parcel 16e6 than 35 acres,not in a subdivision attach a deed with metes <br /> &bounds description recorded pnor to June 1,1972.and current deed <br /> Mining claim(attach copy of deed or survey)Name/#: <br /> O Square 40 acre parcel as deactibed In Item 4 I_. . .. ... ---_ -------_ .. . .-_-- <br /> ■ Parcel of 36 or more acres(attach metes a bounds Jescnpbon or turves) AQUA~ flEl(13Sctivtl# i8F2j1i3. <br /> O Other.(attach metes&bounds description or survey) we 10 0 o 1 1 C'1 f t_d i:; 1 tlA 4(10��(I <br /> B.a of acres in txeca C, Ara you itie owner or ins percei9 WR Transaction f otdl S'f 00.00 <br /> 3t3.135 ©YES 0 uo cvuce CHECK#28694 110000 <br /> - - --- - -- -- <br /> D.NAn th:tbe me eniy wet ee INS parcel?M YE6D M0 U+no-itt artier.soar TOPO <br /> MYL,AR n <br /> E awls Pa oti for ropuon.p 2— l <br /> se5 Div_ WD— SA_ MD <br />