DWR_3805493

• Permitno: 323249
• Receipt Number: 10014521
• Document Type - Well Permit: Original File
• Annotated?: No

COLORADO DIVISION OF WATER RESOURCES Office Use Only Form GWS-44(7/2012)
DEPARTMENT OF NATURAL RESOURCES
1313 SHERM.. N ST.,Ste 821,DENVER,CO 80203
Main: 303 866-3581 Fax: [phone] dwr ermitsonline state.co.us DWR Division 5
RESIDENTIAL Note:Alsouse this form toapply for livestock watering Received
Water Wall Permit Application 8/10/2021
Review form in 3tructions prior to completing form. # 10014521
Hand completed fors must be completed In black or blue ink or typed. Order # 9799
1.Applicant Information
Names) 6. Use Of Well check applicabl boxes)
Hughes Family Revocable Trust See instructions to determine use(s)for vt thich you may qualify
A. Ordinary household use in one Sirgle- mily dwelling
Mailing address (no outside use)
P.O. BOX 122 City ❑ B. Ordinary household use in 1 to 3 Single-family dwellings:
store YPcoda
Woody Creek Co) 81656 Number of dwellings:
Telephone(w/area e-mail ❑Home garden/lawn irrigation,n toe teed one acre:
480-686-620 [e-mail] area irrigated s .8.R acre
2.Type Of Application (Check applicable boxes) ❑ Domestic animal watering-(nor-co mercial)
■Construct new well ❑Change source(aquifer) ❑ C. Livestock watering(on farm/ran ran6e/pasture)
❑ Replace exis ing well ❑ Reapplication(expired permit)
❑ Use existing well ❑Rooftop precip.collection 7. ell Data W (proposed)
❑Change or increase use ❑Other: Maumum pumping race Annulamo ttobewithdrawn
3. Refer To(f applicable) 15 9Prn .3 acre-feet
Well Permit# Water Court case# Tote depth Aquiar
100 feet Triturtaq
Designated as n bett nation# well name or—# 8.Water Supplier
Is this parcel within boundaries of a water se ce area?❑I YESKI NO
4. Location f Pro used Well Important!See Instructions If provide name of supplier:
c0unty 9.Type Of Sewage System
Pitkin ' NW ,/fla7SEWSection ownship N ors Range Eorw E Septic tank/absorption leach field
16 IF fX 85 CI Fxi ❑Central system:District name:
Distance or"I aurni action lines(section lines are ryrecelly not properly lines) ❑Vault:Location sewage to be hauled t :
Ft.from rN (—S Ft.from ME lOW
For replacement wells my—distance and direction fromdd well tonewwell ❑ Other(explain)
feet Direction 10. Proposed Well Driller License o tional : 1095
Well location address Include city,State,Zip) Check#wen address is same as In Item 1.
11.Sign or Enter Name of Applicant(s)or uthorized Agent
117 S. Little T xaS Lane Woody Creek, CO. 81656 The making of false statements herein co stit as perjury in the second
degree,which is punishable as a class 1 isd meanor pursuant to C.R.S.
OPtIona: GPS wen I catim infomsfion in urM formal. GPs unit settings Are as fdlows: 24-0-104(13)(a). I have read the stater nts herein,know the contents
Format must be UTM thereof and state that the are true to m nowled e.
r Zone 12 or r Zon 13 Easgng:6.2.3 Sign or e//rr��//name ss),or
subrNtting opPlicalio Date/r Vtldry yy)
Uinta must t Meters .,K,� `ems � $/ (0 Z�
Datum must be NA 3 Northing: 6.2.3 s �J
Unit must be set to tr nor #signin pint name end title
Wee GPS unit chec for abowf?❑ ES Remember to set Datum to NAD83 ��e n //U& �S O ) 4 ,
5. Parcel On hich Well Will Be Located Office Use Only f J
You m Jet attach a current deed for the subject parcel uses map name DWF map I o. s,,,ya,»q81
A.You must chei k and complete one of the following:
■ Subdivision:Name Little Texas
Receipt area only
Lot 19 Block Filing/Unit
❑ County exam piion(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)Name/#:
❑ Square 40 acre parcel as described in Item 4
❑ Parcel of 35 or more acres(attach metes&bounds description or survey) ADUAMAP
❑ Other:(attach metes&bounds description or survey) WE
B.#of acres in parcel C.Are you the owner of the parcel? WR
•52 t I YES❑I NO
CWCa
D.Will this be the onl war on the parcel?17 VES93 NO(if no—Ilal Omer wells)
TOPO
E. stale EarcellD#(a onap:2643-164-01-014 NYLAR 5
ass DIV_ WE 3 RA MD