2012-11-02_REVISION - M1984094 (3)

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7.10. For warehouses, what is the square footage of floor space? 7.11. For schools without cafeteria, gym and showers, how many students? 7.12. For schools with cafeteria, gym and showers, how many students? 7.13. For automobile service station without car wash, how many pumps? 7.14. For all commercial enterprises, how many square feet of irrigated lawn and garden? 7.15. For any other type of commercial enterprise, describe the number of employees, process water, wash water, or other types of water use? 7.16. Square feet of lawn and/or garden irrigation: 7.17. Number of single family dwellings: 7.18. Number and type of livestock and other animals: 7.19. Surface area of ponds (in square feet): 8. Type of wastewater treatment (septic tank and leach field, evapotranspiration system, sewer line to wastewater treatment plant): 9. Approximate distance to the nearest flowing stream: 2 00 / N7 10. Name of the nearest flowing stream: .5 O v+ t f /a . L P I understand that the Board of Directors ( "Board ") of the Headwater Authority of the South Platte will rely upon the statements I have made in this Application and that such statements are subject to the provisions of C.R.S. § 18 -8 -503. C.R.S. § 18 -8 -503 states that a person commits second degree perjury if he /she makes a materially false statement (i.e., one that he /she does not believe to be true) while under oath with the intent to mislead a public servant in the performance of the servant's duty. I understand that the Board's approval of this Application may be rescinded, whether or not the Board institutes civil or criminal proceedings against the Applicant, if it is determined that one or more of my statements herein are materially false. I understand that the Board may assess an additional amount at closing to supplement the Application Fee as necessary to cover actual costs related to reviewing and processing this application as provided for in ¶ 2 of the HASP Rules and Regulations. APPLICANT: STATE OF ( 6 ) �c ) ss. COUNTY OF �t v ) The foregoing instrument was acknowledged before me this 0 of Sz /Y/ i r, 20P k, by /vl i (./o e j / ' (/ 'l c r- Witness my hand and official seal. My comui i.n x•, e • :174/ q O /3 /� ? Notary Public WANDA S STEVENSON NOTARY PUBLIC STATE OF COLORADO Page 2 of 2 CP \I \II Ri I \I II \iI.. \PI'I IC V1111::1110.10% 11) ,1,