HomeMy WebLinkAbout20120821.tiff Scanning Cover Sheet •
• for
Septic Permits
Permit # G19860084
Permit Type: Health/EHS History/EHS Conversion History
Situs Street Address 25652 CR 40
Situs City, State, Zip •
Sec/Town/Range: 32-04N-64W Application Status: Finaled
Application Date: 03/11/1996
Parcel # (12 digits) 105332000010-R4286986
•
Owner Full Name: PLUSS TURKEY FARMS
Owner Address: 25520 WCR 40
KERSEY,CO 80644
Owner Phone #: 303 2846453
Contact Name:
Contact Address:
Contact Phone#
Information above has been Verified in Accela by emp/ovee noted below
X December 18, 2008
Processed by: Date
•
Report ID: EHS00024v003 2012-0821 Page 1 of 1
Print Date-Time: 12/18/2008 1:15:25PM
• AL-APPLICANT; COPY--WCHD WCHD EHS MAY, 1984
- .
•106F INDIVIDUAL SEWAGE DISPOSAL. SYSTEM PERMIT NO. G-860004
WELD COUNTY HEALTH DEPARTMENT NEW PERMIT
ENVIRONMENTAL HEALTH SERVICES
1516 HOSPITAL ROAD, GREELEY, CO 80631
353-0635 EXT.2225
OWNER F'LUSS TURKEY FARMS ADDRESS 25520 WCR 40 PH (303) 284 -64
KERSEY CO 60644
ADDRESS OF PROPOSED SYSTEM -
KERSEY • CO 80644
LEGAL DESCRIPTION OF SITE : W2 SEC 32 TWF 4 RNG 64
SUBDIVISION: LOT 0 BLOCK 0 FILING 0
USE TYPE : OTHER SERVICE BUILDING
SERVICES : PERSONS 8 BATHROOMS 1 .00 - LOT SIZE 320.00 ACRES
BEDROOMS 0 BASEMENT PLUMBING NO WATER SUPPLY F'WE:LL
/
APPLICATION FEE $150.00 .'
REC' D BY RANGEL, MARY SIGNED BY BARRY KRAMISH
DATE 04/03/86.. ' . DATE 04/03/86 -
PERCOLATION RATE . 12.0 MIN PER INCH LIMITING ZONE 8 FEET
SOIL TYPE SUITABLE PERCENT GROUND SLOPE i'% DIRECTION W
REQUIRES ENGINEER DESIGN NO
FROM THE APPLICATION INFORMATION SUPPLIED AND THE ON-SITE SOIL_ PERCOLATION DATA
THE FOLLOWING MINIMUM INSTALLATION SPECIFICATIONS ARE REQUIRED :
• SEPTIC TANK 1 000 GALLONS, ABSORPTION TRENCH 174 'SQ. FT.
OR
ABSORPTION BED 237 SQ. FT.
IN ADDITION, THIS PERMIT IS SUBJECT TO THE FOLLOWING ADDITIONAL TERMS AND
CONDITIONS :
THIS PERMIT IS GRANTED TEMPORARILY TO ALLOW CONSTRUCTION TO COMMENCE. THIS PERMIT
MAY BE REVOKED OR SUSPENDED BY THE WELD COUNTY HEALTH DEPARTMENT FOR REASONS SET
FORTH IN THE WELD COUNTY INDIVIDUAL SEWAGE DISPOSAL SYSTEM REGULATIONS INCLUDING
FAILURE TO MEET ANY TERM OR CONDITION IMPOSED THEREON DURING TEMPORARY OR FINAL
APPROVAL . THE ISSUANCE OF THIS PERMIT DOES NOT CONSTITUTE ASSUMPTION BY THE
DEPARTMENT OR ITS EMPLOYEES OF LIABILITY FOR THE FAILURE OR INADEQUACY OF THE
SEWAGE DISPOSAL SYSTEM.
TC- 6 ---- --gto TURNER, MILLIE 04/08/06
ENVIRONMENTAL SPECIALIST DATE:
Owl 4—3—fie
THIS PERMIT IS NOT TRANSFERABLE AND SHALL BECOME VOID IF SYSTEM CONSTRUCTION HAS
NOT COMMENCED WITHIN ONE YEAR OF ITS ISSUANCE. BEFORE ISSUING FINAL APPROVAL OF
THIS PERMIT THE WELD COUNTY HEALTH DEPARTMENT RESERVES THE RIGHT TO IMPOSE ADDI-
TIONAL TERMS AND CONDITIONS REQUIRED TO MEET OUR REGULATIONS ON A CONTINUING BA-
SIS. FINAL PERMIT APPROVAL IS CONTINGENT UPON THE FINAL INSPECTION OF THE COM-
PLETED SYSTEM BY THE WELD COUNTY HEALTH DEPARTMENT.
SYSTEM INSTALLER FINAL INSF'EC .ON ATErbillA/
SYSTEM ENGINEER -_----AF'F•ROVAI_. - i _.___._
TYPE OF SYSTEM INSTALLED - .D..- RONME TAL SPECIALIST
ISSUANCE OF THIS PERMIT DOES NOT IMPLY COMPLIANCE WITH OTHER STATE, COUNTY
Oi LOCAL REGULATORY OR BUILDING REQUIREMENTS, NOR SHALL IT ACT TO CERTIFY THAT
THE SUBJECT SYSTEM WILL OPERATE IN COMPLIANCE WITH APPLICABLE STATE, COUNTY AND
LOCAL REGULATIONS ADOPTED F'ERSUANT TO ARTICLE 10, TITLE 25, CRS 1973, AS AMENDED ,
EXCEPT FOR THE PURPOSE OF ESTABLISHING FINAL APPROVAL OF AN ]INSTALLED SYSTEM/ FOR
ISSUANCE OF A LOCAL.. OCCUPANCY PERMIT PURSUANT TO CRS 1973 25--10--1 1 1 (2) . {
a
,�►a
R waz
`, '‘'' 1 111( 040IUA Uca ice'
i
• -...ki_\ bog
• N�- riot., ra5b g e
7)4
f -
.,.. .
344 . .
. . .
. .
. .
. .
0
fp. A
4
ö )6F,
INDIVIDUAL SEWAGE DISPOSAL SYSTEM PERMIT NO. G-8600
WELD COUNTY HEALTH DEPARTMENT NEW PERMIT
ENVIRONMENTAL HEALTH SERVICES .
1516 HOSPITAL ROAD, GREELEY, CO 60631
353-0635 EXT.22 2 5
OWNER PLUSS TURKEY FARMS ADDRESS 25520 WCR 40 PH (303) 264-<
KERSEY CO 80644
ADDRESS OF PROPOSED SYSTEM 25520 WCR 40
KERSEY CO 80644
LEGAL DESCRIPTION OF SITE: W2 SEC 32 TWP 4 RNG 64
SUBDIVISION : L O T 0 BLOCK 0 FILING 0
USE TYPE : OTHER SERVICE BUILDING
SERVICES : PERSONS 8 BATHROOMS 1 .00 LOT SIZE 320.00 ACRES
BEDROOMS 0 BASEMENT PLUMBING NO WATER SUPPLY PWEI._L
APPLICATION FEE $150.00
REC ' D BY RANGEI_, MARY SIGNED BY BARRY KRAMISH
DATE 04/03/86 DATE 04/03/86
PERCOLATION RATE I-42-7 _ MIN PER INCH LIMITING ZONE FEET �
SOIL TYPE Jr PERCENT GROUND SLOPE 1_"/. DIRECTION elf
REQUIRES ENGINEER DESIGN )
FROM THE APPLICATION INFORMATION SUPPLIED AND THE ON—SITE SOIL PERCOLATION DATA
THE FOLLOWING MINIMUM INSTALLATION SPECIFICATIONS ARE REQUIRED :
SEPTIC TANK i 2 'v GALLONS, ABSORPTION TRENCH L 7_ SQ. F T.
• OR
• ABSORPTION BED ?747SQ. FT.
IN ADDITION, THIS PERMIT IS SUBJECT TO THE FOLLOWING ADDI TIONAL TERMS AND
CONDITIONS : —•---•___—•—
THIS PERMIT IS GRANTED TEMPORARILY TO ALLOW CONSTRUCTION TO COMMENCE. THIS PERM
MAY BE REVOKED OR SUSPENDED BY THE WELD COUNTY HEALTH DEPARTMENT FOR REASONS SE
FORTH IN THE WELD COUNTY INDIVIDUAL SEWAGE DISPOSAL SYSTEM REGULATIONS INCLUDJ:N
FAILURE TO MEET ANY TERM OR CONDITION IMPOSED THEREON DURING TEMPORARY OR FINAL
APPROVAL. THE ISSUANCE OF THIS PERMIT DOES NOT CONSTITUTE ASSUMPTION I:tY THE '
DEPARTMENT OR ITS EMPLOYEES OF LIABILITY FOR THE FAILURE OR INADEQUACY OF" THE
SEWAGE DISPOSAL SYSTEM.
• 1
4. ' *0 , p� ENVIRONMENTAL SPECIALIST A-•C:
THIS PERMIT IS NOT TRANSFERABLE AND SHALL BECOME VOID IF SYSTEM CONSTRUCTION HA
NOT COMMENCED WITHIN ONE YEAR OF ITS ISSUANCE. BEFORE ISSUING FINAL APPROVAL 0
THIS PERMIT THE WELD COUNTY HEALTH DEPARTMENT RESERVES THE RIGHT TO IMPOSE ADDI
TIONAL TERMS AND CONDITIONS REQUIRED TO MEET OUR REGULATIONS ON A CONTINUING BA
SIS. FINAL PERMIT APPROVAL IS CONTINGENT UPON THE FINAL INSPECTION OF THE COM-
PLETED SYSTEM BY THE WELD COUNTY HEALTH DEPARTMENT.
•
ti4 WELD COUNTY HEALTH DEPARTMENT ENVIRONMF:NTA1. HEALTH SERVICES
.
CI I ( EVALUATIOn 0i•n< c Pic`cs 77,,,,-
A„/....K.?
Apeo. 5-4...0-0 '7 v s1c< �_ 5--5-01-05--5-01-5--5-01-0 & -- Pt_ iA0 PT w✓ 1-- s1.1._ IC( R
/ `
• c < le j I g-G Sub Lo Block Filing_
'( RCOLATION TEST DATA : Start Time 3 t
•
Hole Hole H2O 33 !C31t D 35 min .
no . Depth Remain Y ✓ inch
inch inch rain . min . min .. min . min . min . oln . • min . min .
a I >i I/ie %'
D.. ta-AI 1I,/re 1 '-F
. ily 1.5-r% ,, %y ► f? c/r-
•
6 ICI ' se
ell measurements in .n<n unless otherwise indicated.
Total
- add 1120 f� �-�
Environmental Health Spec : ails : 1!'I'ff�� 4 ./{{ai .% Awe ra Ee Ra CC/j��
r
?LOT PLA:: SOIL PROFtI.!:
Deoch Description
inches
(!3—EYArs' •
, 0 3yas�
Ce Pag
N1 1', 0
•
S A/
... .,.._....... _.._. . ........ v•. r rw• r.r•rN 1rrr1 , 1 Il.lT
WV
f
_JP1061, APPLICATION FOR INDIVIDUAL SEWAGE DISPOSAL SYSTEM NO. G-86
, WELD COUNTY HEALTH DEPARTMENT • NEW Af'F'LICATIG
ENVIRONMENTAL HEALTH SERVICES
1516 HOSPITAL ROAD, GREELEY, CO 80631
353-0635 EXT.'2'?25
OWNER F'LUSS TURKEY FARMS ADDRESS 25520 WCR 40 PH (303) 284-
KERSEY CO 80644
ADDRESS OF PROPOSED SYSTEM 25520 WCR 40
KERSEY CO 80644
LEGAL DESCRIPTION OF SITE : kiJ2 SEC 32 TWP 4 RNG 64
SUBDIVISION: btc`ok. LOT 0 BLOCK 0 FILING 0 '
USE TYPE : OTHER 54)" -r eRICUL1'URAL.
SERVICES : PERSONS 8 BATHROOMS 1 .00 LOT SIZE 32000 ACRES
BEDROOMS 0 BASEMENT PLUMBING NO WATER SUPPLY F'WELL
APPLICANT ACKNOWLEDGES THAT THE COMPLETENESS OF THIS APPLICATION IS CONDITIONAL
UPON FURTHER MANDATORY AND ADDITIONAL TESTS AND REPORTS AS MAY BE REQUIRED BY T•
WELD COUNTY HEALTH DEPARTMENT TO BE MADE AND FURNISHED BY THE APPLICANT OR BY T
WELD COUNTY HEALTH DEPARTMENT FOR PURPOSES OF THE EVALUATION OF THE APPLICATION
AND-THE ISSUANCE OF THE PERMIT IS SUBJECT TO SUCH TERMS AND CONDITIONS AS DE:EME
NECESSARY TO INSURE COMPLIANCE WITH RULES AND REGULATIONS ADOPTED UNDER ARTICLE
i0, TITLE 25, CRS 1973, AS AMENDED. THE APPLICANT CERTIFIES THAT THE PROPOSED
SYSTEM WILL NOT BE LOCATED WITHIN 400 FEET OF A COMMUNITY SEWAGE SYSTEM. THE
UNDERSIGNED HEREBY CERTIFIES THAT ALL STATEMENTS MADE, INFORMATION AND REPORTS
SUBMITTED HEREWITH AND REQUIRED TO BE SUBMITTED BY THE APPLICANT ARE:, OR WILL E+
RESENTED TO BE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF. AND
l'_DESIGNED TO BE RELIED ON BY THE WELD COUNTY HEALTH' DEPARTMENT IN EVALUATING
THE SAME FOR PURPOSES OF ISSUING THE PERMIT APPLIED FOR HEREIN. I FURTHER LJNDE
STAND THAT ANY FALSIFICATION OR MISREPRESENTATION MAY RESULT IN THE DENIAL OF T
APPLICATION OR REVOCATION OF ANY PERMIT GRANTED BASED UPON SAID APPLICATION ANL'
IN LEGAL ACTION FOR PERJURY AS PROVIDED BY LAW.
APPLICATION FEE $150.00 BARRY AMISH
RE:C ' D BY RANGEL, MARY _. _. .___.. .___..____OAS/D3r$6
DATE 04/03/86 OWNS AGENTS GNATURE DATE
•
.._
WATER SUPPLY INFORMATION SUMMARY
• Section 30.28.133,Id), C.R.S. requires that the applicant submit to the County,'Adequate evidence that a water supply that
is sufficient in terms of quantity, quality and dependability will be available to ensure an adequate supply of water.
1. NAME OF DEVELOPMENT AS PROPOSED
Davtt Oil Fteld Con4,whon , LLC
2. LAND USE ACTION Lgt, by 45 pitted gt.rtu,A
3. NAME OF EXISTING PARCEL AS RECORDED /05 55 Z 000010
SUBDIVISION FILING BLOCK LOT
4. TOTAL ACREAGE 15tgZ 5. NUMBER OF LOTS PROPOSED 5 PLAT MAP ENCLOSED YES
6. PARCEL HISTORY: Please attach copies of deeds,plats or other evidence or documentation.
A. Was parcel recorded with county prior to June 1, 1972? }g YES 0 NO^__
B. Has the parcel ever been part of a division of land action since June 1, 1972? 0 YES.6r NO
If yes, describe the previous action
7. LOCATION OF PARCEL - Include a map deliniatinp the project area and tie to a section corner.
L $ IV I SECTION 3'Z- TOWNSHIP 4 El. N OS RANGE 64 GE Iff W
AiP CIPAL MERIDIAN: yr 6TH 0 N.M. 0 UTE 0 COSTILLA
T - Location of all walls on property must be plotted and permit numbers provided.
Surveyors plat * Yes 0 No N not, scaled hand drawn sketch 0 Yes 0 No
9. ESTIMATED WATER REQUIREMENTS- Gallon per Day or Acre Fot per Year 10. WATER SUPPLY SOURCE
la EXISTING 0 DEVELOPED ' J�NEW WELLS -
• WELLS SPRING norm)AOIFn6.(Cilia as
HOUSEHOLD USE # of units GPD AF WELL PERMIT NUMBERS O AuunAt O uPPER ARUM
/075292- - O W?tB Carson O LINER ARAPAROE
COMMERCIAL USE # of S.F. 315 GPO AF 7085 °Wye wwaa 7s DA
❑oarvER ❑IANAaIA FIX NW
IRRIGATION # of acres GPO AF
/007 IRRIGATION °fNFP
STOCK WATERING k of head GPO AF 0 MUNICIPAL
O ASSOCIATION WATER COURT DECREE CASE NO.'S
OTHER GPO AF 0 COMPANY
O DISTRICT
TOTAL 376 GPO AF NAME
LETTER OF COMMITMENT FOR
SERVICE 0 YES 0 NO
11. ENGINEER'S WATER SUPPLY REPORT 0 YES *-NO IF YES, PLEASE FORWARD WITH THIS FORM. (This may be required before our review is completed.)
12. TYPE OF SEWAGE DISPOSAL SYSTEM
;TIC TANK/LEACH FIELD 0 CENTRAL SYSTEM • DISTRICT NAME
O LAGOON 0 VAULT - LOCATION SEWAGE HAULED TO
O ENGINEERED SYSTEM (Attach a copy of engineering daienl 0 OTHER
COLORADO DIVISION OF WATER RESOURCES Office Use Only Form GWS-45(07/2009)
DEPARTMENT OF NATURAL RESOURCES
1313 SHERMAN ST,RM 818, DENVER,CO 80203
phone—info:(303)866-3587 main:(303)866-3581
fax:(303)866-3589 http://www.water.state.co.us•
GENERAL PURPOSE
Water Well Permit Application
Review Instructions on reverse side prior to completing form.
The form must be completed in black or blue ink or typed.
1. Applicant Information 6. Use Of Well (check applicable boxes)
Name of applicant Attach a detailed description of uses applied for.
135 Cvloa - t o I-6J Wm
5 r L LC- ❑Industrial ❑Dewatering System
Mailing address � L, 1 ❑ Municipal ❑Geothermal(11 production or 0 reinjection)
Rood W (O'1 ti`' Sire-a 0 Irrigation
CI Other(describe):
city State Zip code 12 Commercial
Meretam KS (WWO2o2 - 370O 7.Well Data (proposed)
Telephone It .y b cn 7E-mail(Opbona)
/]IJ) � 1� D7 J` I Madrtwmpumping rate gpm Annual amount to be withdrawn
t'1 Y+ ru t acre-feet
2.Type Of Application (check applicable boxes) 15 3
Total depth / feet f-Aquifer
❑ Construct new well ❑Change source(aquifer) z3t-1' At2ifll(G rot �t��
❑ Replace existing well 0 Reapplication(expired permit)
SUse existing well 0 COGCC well 8.Land On Which Ground Water Will Be Used
❑Change or increase use ❑Other: Legal Description(may be provided as an attachment)) to .N
3. Refer To (if applicable) W lit E 'IZ Set 3i I TL{ r" ( R frz `� 4
Well permit* Water Court case*
Designated Basin Determination tt Well name or*
4. Location Of Proposed Well (Important! See Instructions) (If used for crop irr gation,a ache scaled map that shows i gated area.)
County1 ( L
W/IA 4l,o 1/4 of the e 1/4 A. *Acres B.
Ownerlip ( 'L'J
Section 4 Township NorS Range EorW Prindpat Mendian )60r/ TJL dolt rad* rLtKit {U
3 LI p❑ Log
❑ vi... C. List any other wets or water rights used on this land.
Distance[of well from section lines(section lines are typically not property lines) Lv
(8%O FL from❑N 5S Z3So FL from E E❑W 9.Proposed Well Driller License#(optional):
For replacement wells only-distance and direction from old well to new well 10. Signature Of Applicant(s) Or Authorized Agent
feet direction The making of false statements herein constitutes perjury in the second
Well location address(Include City,State,Lp) ❑check if well address is same as in Item 1. degree,which is punishable as a class 1 misdemeanor pursuant to C.R.S.
24-4-104(13)(a). I have read the statements herein,know the contents
thereof and state that they are true to my knowledge.
Sign here(Must be original signature) Date
Optional: GPS well location information in UTM format You must check GPS unit for
required settings as follows:
/IN//
Format must be UTM Print name 8 ' / sett,nng 1�Ns44ast /�
❑Zone 12 or O Zone 13 Easting 7�( y BA/ayb1• ((fir/ rga ( ais �llo ,sj%j-13 is
Units must be Meters - [U,
Datum must be NAD83 Office se(lily
Northing
Unit must be set to hue north USGS map name DWR map no. Surface elev.
Was GPS unit checked for above? 0 YES Remember to sat Datum to NAD83
5. Parcel On Which Well Will Be Located Receipt area only
(YOU MUST ATTACH A CURRENT DEED FOR THE SUBJECT PARCEL)
A. Legal Description(may be provided as an attachment).
et af{etckcd 6%hifrif A at trial
coy Parcel le LPlttnTur4-ac.1Fat'tt)
B. f of acres in parcel C. Owner AQUAMAP
(4801- be)ColoracloiloWvis,La WE
•D. Wit this be the only well on the parcels EYES NO(if no-list other wells) WR
cWCB
E. State Parcel l0*(optional) TOPO
MYLAR
S85 DIV_ WD_ BA_ MD
Form No. ,
GWS-68
• 10/2011 EXISTING WELL INFORMATION AND INSPECTION FORM
Division of Water Resources, 1313 Sherman St., Ste 821,Denver,CO 80203
PLEASE COMPLETE THIS FORM IN BLACK INK
PERMIT NO: RECEIPT NO: DIV: WD: _ '
Existing Well Location: NJ ) % of the SP. Y., Sec. 3 Z_, Twp 4 , Rng 441, (a P.M.
I$ feet from Nflsec. line, es>$0 feet from
th:0 sec. line; County WtIA
Existinq well owner: Name: ''COIOYa.do-4O Id
Mailing Address; q000 W win- 51/4-vetk
City/State/Zip MU r taw( X S (o(v 2,Dl-t-3700Telephone: (0I5 ) (n'lly -8'152
Description of parcel (sut)division, lot, blk, fig):' Size le ac
Existing well locationathivisual conditions: If stating no, please explain
Type of Existing Wel(Drilleg)Hand Dug, Spring Well, Gallery Well, Gravel Pit, Other
Distance to nearest septic tank/sewer line (approximate) 2 X0O feet
Distance to nearest leach field (approximate) 2/00 feet
Is the well in a clean and sanitary location? WS
is the well maintained in a clean and sanitary condition? yes
Is the ground at the surface sloped away from the well for proper drainage? G'eS
Is the surface surrounding the well firm and stable? y{5
Is the well situated in a well house or vault? (4C r If so, is the well house or vault in good repair
and condition? qtr'
Existing well construction and materials: If stating no, please explain
Is the well equipped with a sanitary well seal/cap? IIL�
• Is the well constructed with steel casing at the surface? 7 Lig4
Does the casing extend at least one (1)foot above the surf ce? gib
Casing size (,/ in; Estimated well depth 239' feet '
Who constructed well? Na ; Who installed pump? Via
Current uses of existing well: Were the existing uses initiated prior to May 8, 1972?
Household use in single-family dwellings
)Watering of poultry and/or domestic animals
Watering of livestock on farm or ranch; approximately how many head?
Is this a feedlot? ; How many head?
Lawn and/or garden square feet
Crop Irrigation acres
Fire Protection
Commercial exempt for
Other:
Estimated date well constructed ?nor 4b N1Z. ; Estimated date pump installed -2005—
Estimated date of first use located
r +a ('D Z : Estimated flow rates IS gpm
How many other wells are ocated on this parcel? 2- ; Uses: Re-S142 ;
Permit/Case Nos.: SOSS5 A ) 1 O151az- A
Existing Well Owner Signature: Date:
For Office Use Only
Has information above been verified? If not, please note accordingly.
List any problems you have identified: (if none, please state so)
• Date of inspection: Phone Number
Inspected by (print): (signed):
Attach photo(s) if available or needed for further evaluation. Additional comments or information on back.
•
COLORADO DIVISION OF WATER RESOURCES Form GWS-57(10/2011)
DEPARTMENT OF NATURAL RESOURCES
1313 SHERMAN ST.,STE 821,DENVER,CO 80203 Application Receipt No.
main:(303)866-3581 httn://water.state.co.us 1
• fax:(303)866-3589 Online Requests:AskDWR le5D 7f_6 tU,t � f� �/�
Applicant's Name: VyW MAO Ol l Ll=
COMMERCIAL DRINKING AND SANITARY WELL WORKSHEET
Review instructions on reverse side prior to completing The form must be completed in black or blue ink or typed.
1. Name and Type of Business: 88 Colorado 7 told,)1 S t Lw
2. Is this application for a new well?
0 Yes
IV.No If no,is this application for a change of use for an existing well?
9 Yes Permit Number of well(if applicable)
'®No For wells used for drinking and sanitary purposes prior to May 8, 1972,a field inspection of the well to
verify historical uses may be required. See form GWS-12 Registration of Existing Well and
form GWS-12A Statement of Historical Use for further information.
3. Is the parcel the well is located on(or will be located on)within the boundaries of a water service area(water district,
municipality,water company,etc.)or is water available from another source(such as a well)?
❑Yes If yes,indicate what this other source is
ig No (name of water district/supplier,or well permit number)
4. Proposed type of disposal system to be used:
Septic tank/absorption leach field
Central System(district name:)
❑ Vault(location sewage hauled to:)
❑ Other(attach copy of engineering design)
5. Water Demand Calculations(for average factors for water demand see below)
Employees
• Number of X Number of Gallons X Number of Days Employee = Gallons per Year
Employees per Employee per Day Works per Year
2S x (5 x z4,c, = entSoo A
Customers
Number of X Number of Gallons X Number of Days Business = Gallons per Year
Customers per Day per Customer is Open per Year
X X _ 0 B
Other Uses(Note: No uses outside of the building would be permitted for this type of well.)
Type of Use X Gallons per Use per Day X Days per Year = Gallons per Year
net, •
Total amount of water required:
= Gallons per Year
(A+B+C)
= 9Z 62,0
For wells used for commercial drinking and sanitary purposes on or after May 8, 1972, the total water demand cannot exceed
108,600 gallons(1/3 of an acre-foot)per year.
For wells used for commercial drinking and sanitary purposes prior to May 8, 1972,the total water demand cannot exceed 325,900
gallons(1 acre-foot)per year.
General Guidelines for Water Demand in Gallons per Day
Day Workers at Offices—15 gallons/person/day
Food Service Establishments(with toilet and kitchen wastes)—10 gallons/patron/day
Churches(does not include food service)—5 gallons/seat/day
• Overnight Lodging—50 gallons/customer/day
On-Site Proprietor of Overnight Lodging(i.e.on-site owner of a Bed& Breakfast)—80 gallons/person/day
Additional water demand figures may be obtained from a pr(vate water consultant or from a technical reference on this subject.
Hello