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' ' COLORADO DIVISION OF WATER RESOURCES <br />DEPARTMENT OF NATURAL RESOURCES <br />1313 SHERMAN ST., RM. 818, DENVER CO 80203 <br />phone -info: 1303! 866.3587 main: (303) 866.3581 <br />NEW HOUSEHOLD USE ONLY <br />O_ . :..,...n,t..., n.i,. wn .•rmmlwlinn ~ <br />I <br />I <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />1 <br />RCp <br />ACT & ~ 1991 <br />RECEIVED <br />X1116 $ g ~1 <br />~.. ~..,,,,,~a si~"~cEs <br />Water~e Permit A~~ 1~cation <br />1. APPLICANT RIFORMATiON 6. USE OF WELL <br />NNr at apogee <br />11 ORDINARY HOUSEHOLD PURPOSES INSIDE ONE <br />'~ SlNGLE FAMLLY DWEWNO <br />O o 05 (N.QOI/TSIDEUSt~ <br />aY area zb aea. <br /> <br />n1 `.0 80~ $`I 7. WELL DATA <br />T.ra~. "~" 11no4iOe i1" aedu MAXIMUM PRODUCTION RATE OF THE WELL <br />g ~ 0 - 7 5? WILL NOT EXCEED 15 OPM <br />- -2: TYPE Of APPLJCATION '-- - °'- - - - - - ' --- • - -- '- <br /> $. TYPE OF RESIDENTIAL. SEWAGE SYSTEM <br />CONSTRUCT A NEW HOUSEHOLD USE ONLY Septic tank /absorption leach field <br />WB.I ON LESS THAN 35 ACRES [7 Central system <br /> °rtdet nom: <br />3. REFER 70 Gf a ~cade): ^ Vault <br />Monk«Yp raAa aWuWrdemwK ! ~ Ixatlan Nwapa to M hrAad m' <br />MH- ^ Other I.at+e~ mw ar ..a:..~w a.:on) <br />4. LOCATION OF WELL 9. PROPOSED WELL DRILLER ( anal) <br />~, ourt«/a.~tr ou.rte N.T. ue«w iwmM. <br />q,>~ SW t/4 LSE tr4 1nG c oa Q.1 ,., ~ ~0(0~ <br />s.aeae Town.lwo N «s iw. a arw -nfidpa~ Mrid4n t0. SIGNATURE of a icart(s) or authorized a ant <br /> ~ f The makuq of false statanenta herein wnstiuAes pefjuy <br />°:c.K. m me ham section a,N in the secatd degree, which ff putishable a9 a Hess 1 mis- <br /> demeanor pusuant to C.R.S. 24.4-104(131ta1. I have read <br />/~ <br />tTT N I] 6 I E ^ the statements heroin. know the corrGerlta thereat and SUte <br />adm.N. x eoT sso9'+nt aes~N. pr a0necasisl that true, knowk <br /> <br /> <br />5. TRACT O WHICH WELL WILL BE LOCATED <br />A. Yee east dnak «,. of ur foeewfrw • aae ireeodorr _. _ - °"'- _ <br />Rl Subdivision: NameCe~.T Cia:~~E 41t`eeL4TTuc=['arow O ,U O - 6-4 <br />S'p,~, Yt, Ofeas Ua. OAY OWR Map No. <br />Lot a~_Block f FJinp/llnitt <br />D C°unty Fxemption~..,wa...,,..«r...r,n.Tr...w~~ <br />~tmpt- name/I Tract <br />^ Mining claim ee...a..,aa.aa.~Mrl <br />Ckkn name/i DIV <br />O Other i~~ roe Amer m .voir•ir.i <br />s. stateaaltta CO~ <br />IDl! rwewl: CIIECIS TR142Q515 082997 60.00 <br />a a et ip.. sa traex DIV OF YATER RE~tCES WD <br />o. BA <br />THIS WILL BE THE ONLY WH.L ON THIS TRACT <br /> USE MD <br />rtma vwn-.> ta~+>+~ <br />