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JUL- a--1596 09:07 D I U WH TER F LSUUtC E- <br />COLOR,tDO,DIVISION OF WATER RESOURCES <br />DEPARTMENT OF NATURAL RESOURCES <br />1313-SI BF-uL.dAN ST., RM- 818, DENVER CO 80203 <br />phone - info: (303) 866-3587 main: (303) 866-3581 <br />NEW HOUSEHOLD USE ONLY <br />Rsview inst "Ictions Prior to eom letin form <br />1. APPLICANT INFORMATION <br />Nsme of spp)icsrrt <br />John, Elena & Caroline Betts <br />MAWng Address <br />10705 W. 7th Ave. Apt. 6 <br />yea zip code <br />Lakewood, CO 80215 <br />Te)ophonc Number {include area code) <br />303-205-1103 <br />CONSTRUCT A NEW HOUSEHOLD USE ONLY <br />WELL ON LESS THAN 35 ACRES <br />3. <br />MH- <br />a <br />bto s?ts? r. bei4l? <br />AUG 0 31998 <br />1111 t ENG?` "Application <br />Water Well Perini ,Application <br />must be com leted in black ink or ed <br />6- USE OF WELL <br />ORDINARY HOUSEHOLD PURPOSES INSIDE ONE <br />SINGLE FAMILY DWELLING <br />(IO OUTSIDE USE) <br />7_ WELL DATA <br />MAXIMUM PRODUCTION RA'P'E OF THE WELL <br />WILL NOT EXCEED 15 GPM <br />8. TYPE OF RESIDENTIAL SEWAGE SYSTEM <br />eptic tank ! absorption leach field <br />Central system <br />District name: <br />El Vault <br />Location sewage to be ha,ited to: <br />© Other (attach copy of engineering design) <br /> 9. PROPOSED WELL DRILLER toptiorta- <br />4. LOCATION OF WELL License number <br />County Quartcrlquancr Quortar <br />Namc <br />Gilpin /Vij 114 5 tt4 Smith Drilling r? <br />Towrrehip N ors Fangs E orw Rrmcipal Moridion 10. SIGNATURE of applicant(s) or authorized agent <br />X12 3 The making of false statements herein constitutes Perjury <br /> s a dass 1 mis- <br />bl <br />h <br />i <br /> e a <br />a <br />s <br />in the second degree, which is pun <br />Distance of well from section tines <br />3 ?O <br />-- demeanor pursuant to C.R.S. 24-4-104(13)(a). l have read <br />Q, <br />25 know the cgnbents thereof and state <br />statements herein <br />h <br />t- faoen Ej N S tt, from d IE W , <br />e <br />t <br />l <br />d <br />if different from applicant address gf applicable) e. <br />e <br />t a the are true tom know <br />well location addroac, <br />210 CR 279 Central City, CO 80427 U'Act be 014"%aflasnawre <br />d 3U, <br />JA <br />TRACT ON WHICH WELL WILL BE LOCATE <br />- <br />5 D <br />D <br />t <br />. <br />A. You mun check one of the wlawlms - see imtruedons o <br />s <br />Title <br />n a? rt <br />r;J <br /> N <br />k <br />me <br />Cl. Subdivision: Na <br />No. <br />ow; Map <br />fiii, uonly <br />F.Iin <br />Lot f) Block B/Unit/F 141k& lt. ?? - -? <br />itle 7-R1- GH <br />7: <br />Q County Exemp6en leapt *I cou" epaew: e>,u,w?,y emm be artaMoW p1e? r? ?,(rL p?- yyo <br />u - Ak <br /> _ <br />Exempt. name1z Trect #,_, ?7? e ff3a_ <br />L3 M' In claim r.n«n eaeY o, a? A <br />Claimnamel# J.L. Lode Mining Claim ?L plV? <br />13 Other (attach local description to avwicatiom <br />CO <br />S. STATE VAKLxL <br />ID# (epHenor): <br />C. # of acres in vacs <br />3.6 AC <br />D. <br />THIS WILL BE THE ONLY WELL ON THIS TRACT <br />JUL.-30-1998 09;19 303 866 3589 <br />EA54 M433961OB0398 W60 ± <br />DIV OF 9ATER 001+ 0- <br />FA <br />USE MD <br />Form GWS-49 (12!95) <br />TOTAL P.02 <br />P.02