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OB/10/OB 10:10 FA% ~ o~ III IIIIIIIIIIIIIIII URL~ <br />doe <br />FOR OFFICE USE ONLY <br />M NAME NO. WATER DIV: DIST: <br />NOTICE OF INTENT TO CONSTRUCT A NON~IURISDICTIONAL <br />WATER IMPOUNDMENT STRUCTURE' <br />This notice is required per Section 37-67-125, C_R5. (1998). <br />This notice must be submitted io the Division Engineer's Office a minimum of 10 days prior to wnstrudion. <br />OWNER IN(FO1RMATION <br />Name: Rub :.~ SeY. <br />Address: S <br />Street/P.O. <br />Responsible Person: <br />Address: ew.4. C. <br />Street/P.O. <br />Contractor. <br />STRUCTUREINFOfRMATF <br />Name of Dam: L~;. <br />ocation: <br />Option 1 <br />OR <br />Option 2 <br />(PLEASE PRINT OR TYPE NOTICE) <br />r, ~'t,,. on. ~„ <br />~w-~Me A~ <br />ix/ Rural Ro e <br />:~ovc <br />ut/ Rural Route <br />Telephone: ~h3 ) ~~ 3 ~ 30~ <br />Telephone: 3( a3 ),~ 3 "3~~{ 0 <br />State <br />Telephone: ~~ <br />Water Division: Water District <br />%J'/. Sact S ~.J Qtr Sect fJ ~.1 Set3:~, Township: ~ s Range: 6`1 W , P.M <br />Distance of dam from Section tin les O ft from DN ~ S,~ 1L8om fiE OW l <br />I Ubliang GPS: Set to UTM Oatum. Measure on oast of dam at streamllne/oW eL I <br />Northing m_ Easting m_ <br />Dam Dimensions: Verbcal Height: ~~ ft., Length: 75 fl., Slopes: U/S: 3 H:1V, D/S 2 H:1V <br />Reservoir: Surface Area: 2s acres, Capacity. 2 .~ aue feet, Drainage Area:'' I O acres <br />Emeraencv Soillwav Width: ~, ft_, Side Slopes: Z H.1 V, Freeboard: 3 i< ~ <br />Outlet Drein: Type: _ ~,,,~ ,Size: inches, Location <br />Stream Name / or Water Source: <br />Proposed Water Use: W ~ <br /> <br />7/-3/°~ <br />signewre or owner umc <br />t5 tMtGn ~rlgtnnl=-LC L'~EC'[E!1 g'( <br />\~ \~ <br />DWR (1Z9 <br />Signature of Division Engineer Date <br />Vertical height Is 10 feet or less at longitudinal centerline of dam from bwest point of ground surface to flowline crest of spillway, <br />and reservoir is 20 surface acres or Less at high water line, and impounds 100 ave-feet or less of water. <br />2.See Example on reverse sitlB of form <br />'Vertical distance from lrortam of spillway to crest of dam. <br />' If tbnstrugion in reservoir intercepts groundwater (Hole sVeam name that groundwater is tributary tot, a well permit is required. <br />7, <br />