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Scanning Cover Sheet
for
Septic Permits
Permit # SP-0200424
Permit Type: Health / Residential/ New
Sites Street Address 24421 CR 36
Situs City, State, Zip
Sec/Town/Range: 06-03N-64W Application Status: Finaled
Application Date: 09/12/2002
Parcel # (12 digits) 121506000023-R8591000
Owner Full Name: HILL JERRY L
Owner Address: 24421 CR 36
LA SALLE,CO 80645
Owner Phone #: 970-284-6123
Contact Name: HILL JERRY L
Contact Address: 24421 CR 36
LA SALLE,CO,80645
Contact Phone# 970-284-6123
Information above has been Verified in Accela by employee noted below
X li 0, , May 21, 2008
Processej by
ii Date
Report ID: EHS00024v003 Page 1 of 1
Print Date-Time: 5/21/2008 3:10:03PM
FORM NO. f PUMP INSTALLATION AND TEST REPORT For omu use or,.
G4S•32
11/90 STATE OF COLORADO, OFFICE OF THE STATE ENGINEER c7er''s-5`G7.2,
RECEIVED
1. WELL PERMIT NUMBER
2 OWNER NAME(S) ` ens' parcel& N1L� OCT 3 U 20�
Mailing Address F.,7 f p cd 114 L50 y A4Toi l Esouncts
City, St. Zip ,TTL0-7i xS C"3 adrn/Z7 STAM Erri►EER
cct.o
Phone (3 3 ) 9??
3. WELL LOCATION AS DRILLED: All 1/4 �� 1/4,Sec. f. •Twp. 3 lam, Range 44v
DISTANCES FROM SEC. LINES:
J.2.5'0 ft. from S Sec. line. and �d7o ft. from ti) sec, line.
(ram or south) east or vwsq
SUBDIVISION: LOT BLOCK FILING(UNIT)
STREET ADDRESS AT WELL LOCATION: ,7 ye/.7/ lalc,Q _?le , .l,R_c Lc:, Cz A, 46- _
4. pUMP DATA;Type ,s(l, .42 1 b)a Installation Completed 1'44o
Pump Manufacturer :3-41-4 z,Zj Pump Model No. J5_5 via/9 R 2_
Design GPM /6 at RPM 3 y�j� , HP I Ja , Volts , Full Load Amps //.
Pump Intake Depth -/4/0 Feet, Drop/Column Pipe Size / _ Inches, Knd
L4gDmONAL INFORMATiO FOR PUMPS- El GREATER THAT11 50 GPM:
E3
TURBINE DRIVER TYPE: Electric Engine Other AO
Design Head feet, Number of Stages , Shaft size inches.
5. OTHER EQUIPMENT;
Airline Installed❑Ye LrI No, Orifice Depth ft. . Monitor Tube Inst ed El Yes h1 No, Depth ft._
/�Flow Meter Mfg. N Meter Serial No. U/i¢
Meter Readout❑Gallons, 0 Thousand Gallons, Q Acre feet, U Beginning Reading
6. TEST_DATA: r0 Check box if Test data is submItter 1�n Supplemental Form.
r Date _____ _..
Total Well Depth Time �{„�r •
Static Level Rate (GPM) ,C�, .f
Date Measured �� Pumping Lvi.
7. DISINFECTION: Type i'tr a rt4an (L f or in Amt. Used fps dhs•Q1If 1 Try „5�watt•
9. Water Quality analysis available. ❑ Yes al-No
9. Remarks
0. I have read the statements made herein and know the contents thereof, and that they are true to my knowledge
(Pursuant to Section 24-4-104 (13)(a) C.R.S., the making of false statements herein constitutes perjury In the secor
degree and is punishable as a class 1 misdemeanor.)
CONTRACTOR .5,7airn '.i Seavice Inc . Phone (303 ) 6S9-/584 Lic. No.7/5
Mailing Address 202/ WWC 27 Ft.. /_u p f on, L o , S062/
Name/Title (Please type or print) ' 'Signature L�. Dat
Torn Ul. $p a t rt /n rt e a i.r�e n t DWy: /��LP'M1� i th'\p 0
Kul MA
tralin ' WELL CONSTRUCTION AND TEST REPORT For ostaatC1,VF+r
►a,. STATE OF COLORADO, OFFICE OF THE STATE ENGINEER
t4WELL PERMIT NUMBER _ 223683 S E P 1 3 2000
. am. _♦
2 OWNSAJd NE(S) Jerry .8( .Pamela Hill wA f f R Kt s,oumu S5r.rE r,, ,n,cER
Mang Address 5388 South NP1 snn Coto
Cxy, St aP. Litt1 e on, t,n 1EIQ0, 27
Phone ( 30)3 933-2886 D 46g5 IQ 1 Z
,mom'
'a WEU,J.00ATION AS DRI : NE 1/4.sww 114b sec fL T1wp. 1 N ,Rt nge 6 4 _.__—.---hL,.
DISTANCES FROM SEC. LINES:
1250 ft. from S Sec. One. and 2300 ft.from, tLitur we.;Soc. Una OR
SUBDIVISION: - LOT. BLOCK_ FIUNG(UNfr) ,
STREET ADDRESS AT WELL LOCATION: 2 4 421 Rd.. 36 ,
4. GROUND SURFACE ELEVATION 1L DRg11NG MEI1iOD Rotary
DATE COMPLETED_L- 2 6 TOTAL DEPTH i, �_ft. DEPTH COMPLETED a__ ,..aft•
S. GEOLOGIC LOG S. HOLE DIAM (In.) From (ft) To (ft)
o.pat o..orlpdw,of Matatia:(iYDa.Itiza,color,watw LAY 8` 3/4 0 213
0-27 mown sanri _ - 6 1 /4 213 500
27-41 13rnwn Ah 1. -ate __
43..7 e R r etutia-6•a'' ---6•h.a l c 7. PLAIN CASiNG ^
7 9-9 0 ,}zt 1 n P is 1�
9 -1 4 0 R 1 n szh a l e OD on) Kind Wall Size From(ft) To(tt)
L40-21 .3 R1 itsh?1 s 6 5/8 Steel . 188 +1 213
L7 a ter
PERF. CASING: Screen Slot Slzel/1 6" *A w c u tp
4 1/2 PVC .2Q0 188 500
L FILTER PACK 9. PACKER PLACEMENT:
Material N/A Type N/A
Size
Interval Depth � --... 0
10. GROUTING RECORD:
Material Amount Density Interval Placement
RFMAJ :- s Pam* nite . 2Sk e-a 1v4 at cement 32pcia17gal/bag0_213 Pump
ehloreck dded to cpmenr g5bags -
11, DISINFECTION:j pe GranultaerrCphgcrine Amt, Used 33 cupsp dissolved in 5
gallons of
12, 4YEU. It51 DATA; ®Check c �TeSi uiiPbd�e t FCst11 N0. by 3:eI up nie�ntal Well Ts .ough zone
TESTING METHOD A,i,r with a i r
Static Lwei 2 4 9 ft Date/Time msavoed 7-71-n n -• nn Production Rata 12 gPm.
Ptamp(ng level js.-t t i ng rt. Data/Time measured -__-,Test length (hra.) : n E„
at. 500
13. I hrry r..d vw autrm..da made h.v.tn and know tha'ontans.th.r.w,and that char an Imo to mr kno'4.dg..1Purw.l+t to section a4-4.104 (19)(a,
CAL tw rnaldng d Irlw.tat.m.+>b Navin oonemia-4w p)ury in the a.00nd d.pr+and I.pantahabta as a.laea 1 aal.d.m..nor.)
COhTTRACTOR Johns r l i m Phone ( - n k 4 2 3-52 4 6 tic. No. 82 7
N (Please type or print) S ' / Date
;
Llo d John Own r/ r dri / � 0 r-r 9-6-00 J
p 5
/ ,
Title Companies - Change of Owner Name/Contact Aso C O L O RADO
Division o<Water c..
Information ""'°"""°"°"
Order 48180 Permit 223683 Receipt 0455672
Number: Number: Number:
Date 10/4/2024 9:14:52 AM
Submitted:
Title Companies -Change of Owner Name/Contact
eForm Name:
Information
Well Identification
• Permit No 223683
• Suffix N/A
• Replacement Suffix N/A
Well Address
• This is for information only and does not affect the permitted well location. Address
• Address 24421 County Road 36
• City La Salle
• State Colorado
• Zip 80645
Owners and Agents
• Well Owners:
a Name Melling Address Phone Email
1 MEDRANO RAMIREZ,DAMARIZ S 24421 CR 36 LA SALLE,CO 80645 9708884439 DAILY.SEPTIC(DGM AIL.COM
Signature and Certification
This form was submitted by a title company as part of a real estate transaction.
•
COLORADO
lio 0...av Division of Water Resources
Department of Natural Resources
Change in Owner Name/Contact Information for Well Permits
For Use in Connection with a Real Estate Transaction
To be completed by the individuals or entities claiming ownership of a well permit,and submitted by title
companies/settlement agent as an uploaded attachment using the eForm Submittal Tool.
New Well Owner(s)Contact Information:
Names(s)": Damariz S.Medrano Ramirez
Organization': U
Mailing Address': 24421 County Road 36
City,St.,Zip': La Salle,CO 80645
Phone: 970-888-4439
Email(s)": daily.septic@gmail.com
'required fields to submit eForm.
'ONLY enter a name here if the Organization itself OWNS the well.
Well Permit
Well Permit Number" 24421 County Road 36
223683 La Salle,Colorado 80645
'required field(except when using the title company eForm for wells where a valid permit number cannot be identified In those cases,this form can still
be completed and uploaded;however.the permit number would be left blank on this form)
I(we)claim and say that I am(we are)the owner(s)of the well permit described above,know the contents of the statements
made herein,and state that they are true to my(our)knowledge.This filing is made pursuant to C.R.S. 37-90-143. I(we)
understand that filing a Change of Owner Name/Contact Information form is for contact information purposes only. Filing
this form does not convey real property.
Signature of the New Owner(s)' Please print the Signer's Name'&Title Date'
Nit Aat/2 S j'(\r auxO f An71 P,cL `124 12.L\
1
'required fields
Note: If there are multiple owners with different mailing addresses or additional mom is needed for signatures, please
include this as an attachment to the form.
File No.: 2414811 Page 1 of 1
Rev.7/2022
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