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<br />• <br />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 />RESIDENTIAL *INpt<:youm.y.Iwuaethi.lormta.pPNlorriwROCkwelerinp) Water Well Permit Application <br />Review instructions rior to com letin form Must be com leted in black ink or ed <br />1. APPLICANT INFORMATION 6. USE OF WELL (check appropriate entry or entries( <br />h... el .ppew~ //~~ <br />/r,~.O~E (1~~N~~ <br />x`77 (~ Sea inatructbns to detarmkle wale) for whk:h you may qualify -- <br />^ A. Ordinary household use in one single-family dwelling <br />(NO outside use( <br />""""O "°°"' <br />7'ft5 /~f~RK ~1/E,veG~ ^ B. Ordinary household use in t to 3single-family <br />dwellings: <br />Number of dwellings: <br />Crty euta pLp mEe <br />M~~,C~ eO 0 ~6 ~ <br />Home gardmAawn irrigation, not to exceed 1 acre: <br />area irrigated ^ sq. ft. ^ acre <br />Telsphwr N~ne~ 4~el,ee era• ceeel <br />^ Domestic animal watering -- (non-commercial) <br />2. TYPE OF APPLICATION Ichedc applicable boxles)1 C. Livestock waterin lon fens/ranch/rangelpesturel <br />,81 Conmutx new well ^ Use existing well 7. WELL DATA <br />^ RepWce existing well ^ Change /Increase Use <br />^ Change (source) aquifer ^ Reapplicationlslm:.e psmill ""°'""'s~desem <br />~~ gpm w..r .,„em„e. anwn~e <br />s acre-feet <br />^ Other• T•.l e.pm as~+l.r <br />3. REFER TO (if appliwblel: ~~ feet iTl.Lt/f//d/)/ <br />water <oart <ase s ^ Permn. , / $. TYPE OF RESIDENTIAL SEWAGE SYSTEM <br />NrT ,~/~ ^ Septic tank /absorption leach field <br />v.re.l . <br />-VE- Monnodnp noM a<krwwNdgment e <br />MH- ^ Central system <br />District name: <br />weu n.ma ors ~A <br />? ^ Vault <br />Location aewege to ba hauled to: <br />4. LOCATION OF WELL Other (attach copy of engineering design) Dt - <br />Covrny nwrtar/quarter nuarter 9. PROPOSED WELL DRILLER (o 'onaq <br />~P/O .QcA~/r10 NI,J ~/. SE ,~. N-^/. / 1~~..-- <br />Sactien Township N or 5 Rmae E or W y,v.;pr ry.ti., <br />~ 19~/Q(~ ~~~~ / Q(}Ju~ <br />a9 a ® ^ 43 ^ ® 6 <br />t 10. SIGNATURE of applicantlsl or authorized agent <br />oiRSnce,,o/f well fiom sserion Fnss ^/ <br />.2-I J1J k. Irom ^ N ~ S .uvg~ k. from ^ E ®W The making of false Statemems herein constitutes penury <br />in the second degree, which is punlStNble as a class t mis- <br />wr ledi4en e°°rs•, a am..m I.em sppiun.eba~ YI ygr+e41 <br />n1A demeanor pursuam to C.R.S. 24-4-t D411311a). I have read <br />the statements herein, know the ctxnertts thereat and state <br />rR ryt.pan.a wrY «+r ~ aw,e..r °nsetien hem ek wrl m ns.r wrl that they are true to my knowledge. <br />~R feet direction M11°•°'""°"'°'• <br />5. TRACT ON WHICH WELL WILL BE LOCATED ~ ~ <br />A. You must clgpk oro of the tollowiq -see irtructiorr <br />^ Subdivision: Name rm. <br />/Gn ~/G w ~ s/ pne <br />/o -io - 9G <br />Lot na. Block no. Filing/Urrt OPTIONAL INFORMATION <br />^ Ctwnty exemption (attach copy of county approval & survey) <br />Name/no. Tract no. uws m4 ~... pww,,,~,., sul... a«. <br />^ Mining Maim Isrtach <opy of ease or eurveyl <br />N <br />ame/no. Office Use Only <br />DIV <br />, <br />y~ <br />W Other latta<n Mall des<riptbn to spplicationl <br />sE~ Arr ~ D+<sc , <br />co <br />8. STATE PARCEL <br />IDa01 MRaenrl: <br />WD <br />C. I wm M tnM O. Are you 1M owner o} dlia property? <br />DYES ^ NO IH rto - sea detailed inst.( <br />BA <br />E Mrdl this be the only well on this tract? <br />^YES NO M other wNls an on thle tract -see detailed inst.( <br />USE MD <br />~EVL~IE~ g~16~96 /Yi -11 Z~ID FormGWS•ta(11/95) <br />