DWR_3148028

• Permitno: 307251
• Receipt Number: 3683023
• Document Type - Well Permit: Original File
• Annotated?: No

tU 2 11
COLORADO DIVISION OF WATER RESOURCES Office Use On1 Form GWS-44(7/2012)
DEPARTMENT OF NATURAL RESOURCES 'RECEIVED
1313 SHERMAN ST., Ste 821, DENVER, CO 80203 KEGEIVED
Main: [phone] dwr ermitsonline state.co.us
RESIDENTIAL Note:Also use this form to apply for livestock watering OCT 102017 OCT 242017
Water Well Permit Application WATER RESOURCES WATER RESOURC
Review form Instructions prior to completing form. STATE ENGINEER S
Hand completed forms must be completed in black or blue ink or typed. STATE ENGINEER COLO. COLD
1. Applicant Information
Name(s) - - 6.Use Of Well check applicable boxes)
Julie Anderson See instructions to determine use(s)for which you may qualify
❑ A. Ordinary household use in one single-family dwelling
Melling address - (no outside use)
864 WOodcrest Street __ B. Ordinary household use in 1 to 3 single-family dwellings:
city state2 1 Number of dwellings: 3
Bloomington CA 92316
Telephone(w/area code) E-nan - M Home gardentlawn irrigation, not to exceed one acre:
909-421-0885 [e-mail] area Irrigated 1 ❑ sq.ft.0 acre
2.Type Of Application(check applicable boxes) ■ Domestic animal watering-(non-commercial)
a Construct new well ❑Charge source(aquifer) ❑ C. Livestock watering(on farodranchhange/pasture)
❑Replace existing well ❑ Reapplication(expired permit)
❑Use existing well ❑ Rooftop precip.collection 7.Well Data (proposed)
❑Change or increase use ❑Other: Maximum pumping rate Annual amount mbewuwrai,n-
3. Refer To (if applicable) 15 9pm acre-feet
wen perms# water cuun case# Total depth Ayuner
200-300 feet Unknown
Designated Basin Determhtatlan# Well name or# - 8.Water Supplier
Is this parcel Within boundaries of a water service area?❑YES® No
4. Location Of Proposed Well (Importantl See InstrucFions) If es, rovidename of supplier:
9.Type Of Sewage System
La Plata 114ofae 1,4
-- ----- - - - - ■Septic tank!absorption leach field
section Township N or$ Range E or W Printlpal Medtll
22 33 ID ❑ 1 D O ® /v(�J ❑ Central system:District name:
Distance maven from section lines(seuaan lines are typically not properly roue) ❑ Vault:Location sewage to be hauled to:
Ft.from[]N ❑S 'Lv� Ftfrerm❑E ❑W
For replacemem web only—distance are alrecnon mind ra new wen ❑ Other(explain)
feet Direction 10. Proposed Well Driller License#(optional): Beeman
Well location address(Include dry,State,Tip) Check if well address is same as in Item 1.
11. Sign or Enter Name of Applicants)or Authorized Agent
The making of false statements herein constitutes perjury in the second
2311 Rancho Durango Rd., Durango,CO 81303 degree,which is punishable as a class 1 misdemeanor pursuant to C.R.S.
mr�Optional;
cps ll oam information rrxmalloo in t format. DPs con settings ere as idiom 24-4-104(13)(a). I have read the statements herein,know the contents
thereof and state that theyare true to my knowledge.
Format m.el ba u 11
sign tar enter nemi m parson(s)submitting application Data(nnJddlyyyy)
L J 2ona 12 o2li Zane 13 Easting:
Units met toe Meters Julie D.Anderson 1 0/1 012 0 1 7
Datum must be NADe3 Northing _
Unit must be set to true rwrlh d signing print name and this
Remember to set Datum to NAD83
Was GPS unit checketl for above?❑YES
5. Parcel On Which Well Will Be Located Office Use Only
_ (You must attach a current deed for the subject parcel) uses nap rums - - - - -- DWR map no. swan else.
A.You must check and complete one of the following:
Lj Subdivision:Name Rancho Duranqo Receipt area only
Lot 36 Block Filing/Unit 1
❑ County exemption(attach copy of county approval&survey)
Name/# Lot#
❑ Parcel less than 35 acres, not in a subdivision attach a deed with metes
&bounds description recorded prior to June 1,1972,and current deed
❑ Mining claim(attach copy of deed or survey)NameNF:
Tr insaction#. 3883023
❑ Square 40 acre parcel as described in Item 4 p 11 Parcel Parcel of 35 or more acres(attach metes&bounds description or survey) AOUAMAP Transaction Total: $100,00
❑ Other:(attach metes&bounds description or survey) WE CREDIT CARD $100.00
B.#mausamparcel l;.are you the owner of cols parcel? WR
40.62 ® 0 NO
cwca
D.Will this be the only"it on this pace?91 YES[9 NO Of no—list other wells) TOPO
E. state Parcel[DO(mptionm): 6949_222-00-089 MYLAR ] q,.�
SB5 DIV 1 WE)—�/ BA_ MD