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DIVISIO0 CHECKLIST <br /> WELL PERMIT APPLICATIONS <br /> Applicant Name 94PISM <br /> Application in BLUE or BLACK �/J�ink: ®— <br /> Correct Fee: p-caeeir#-- I�cc,* 3Lb'3oZ3 RECEIVED <br /> ❑ Credit Card receipt attached <br /> ❑ Money Order OCT 2 4 ZOIl <br /> Type of permit application <br /> ❑ 1) GWS46 Monitoring/Observation Well WATER RESOURCES <br /> El2) GWS-45 General Purpose Well, Type: STAT CEONLGOINEER <br /> 2'3) GWS44 Residential Well <br /> ❑ 4) GWS-78 Rooftop Precipitation Collection System ^yam/ <br /> Previous permit# County—la a I r a fc, <br /> Tributary River System AlmctS <br /> Location: AJ, I 114 NJ1/4, Section 7iZ , TWP 37 N, RNG /D E <br /> Distances from section lines N/S ENV <br /> UJM Zone 13 Coordinates: Easting Northing <br /> Rule 6.2.3 <br /> ❑Over-appropriated <br /> ❑ Subdivided before June 1, 1972 <br /> ❑ Subdivision Name Lot#_ Filing <br /> ❑ Required attachments (proof of pre-1972, legal description or plat) <br /> ❑ Square 40 acre parcel <br /> ❑ Augmented - Case no. Aug Plan <br /> ❑ Non-overappropriated <br /> ❑ Ownership of Property Verified - Circle one (Deed attached) (Parcel Ownership Verified)(Signature Authorization Attached) <br /> ❑ Variance type well <br /> ❑ Request for variance <br /> ❑ Construction diagram <br /> ❑ 600 foot spacing statements �/q <br /> [; -eounty parcel number 5S & / -Z 2 Z- 00-OP?— <br /> .3"Water District /' / <br /> Comments: <br /> 16, t _xA43aZ, 6-r Z,3 <br /> Signature: Date: Ja rev4/n <br />