HomeMy WebLinkAbout960464.tiff OFFICE OF THE STATE ENGINEER
COLORADO DIVISION OF WATER RESOURCES
821 Centennial Bldg., 1313 Sherman St., Denver, Colorado, 80203
Main No. (303) 866.3581, Records No. (303) 866.3447
CHANGE IN OWNERSHIPIADDRESSILOCATION REQUEST
WELL PERMIT NO. FROM:JU CAE
DATE: ( 11 7q5-
W4d- L l t N
!(07 cP «8
ovC. CO 8072q
This Change in OwnershiplAddresslLocation form is being returned to you for more complete or a correction of data.
Complete andlor amend as necessary and return as soon as possible. CORRECTIONS ARE TO BE MADE ON THE GWS-11
FORM. PLEASE INITIAL ANY CHANGES YOU MADE TO THE FORM.
1.._/ Complete the well owner name and address. -7
2.x Enter or verify the permit number. Our records show permit number Z3 Enter � at this location.
3._ Complete the blanks for the location of the well where checked.
3A._ The location given does not correspond to the location on the well permit Please amend or explain the discrepancy.
(It is possible that a new application for a permit to reflect the constructed location will be necessary.) Our records
indicate that the well is located in the 114 of the 114 of Sec. , Township South or North,
Range _ East or West, P.M.
Feet from North or South and Feet from East or West Section lines.
4._ Complete the blanks for the location of the Livestock or Erosion Control Dam.
5. Indicate the reasons, either name, address andlor location
6._ The new well owner must sign the document Print or type your name in the first block. If signing as a
representative of a company who owns the well, then your title must also be included in the first block. Sign the
second block and date the last block.
7._ We can not locate the permit for this well with little or no information, please contact your local tax assessor for
the legal description of your property. Names of previous owners, and Subdivision, lot and block number may also
help in the search. Thanks.
Other:
960464
FORM NO. STATE OF COLOR, For Office Use only
O ys-it OFFICE OF THE STA ENGINEER
07/93
818 Centennial Bldg., 1313 Sherman St, Denver,Colorado 80203
(303)866-3581
PRIOR TO COMPLETING FORM, SEE INSTRUCTIONS ON REVERSE SIDE
CHANGE IN OWNERSHIP/ADDRESS / LOCATION
WELL PERMIT, LIVESTOCK TANK OR EROSION CONTROL DAM
1. NEW OWNER
NAME(S) Wll'\C\ • . a.- Les 1le-. flA cur-1--i n .
Mailing Address ss `(a p 1 C1 Lk)W,C • (R,• \.ce
City, St. Zip CepAler) o'kO C -1 JR
Phone (t30 7 ) (p3€ - 5 t ckO((et-T+11 Jury I-5, cc)
2. THIS CHANGE IS FOR ONE OF THE FOLLOWING:O-w- ge 1h b o
❑ WELL PERMIT NUMBER
❑ LIVESTOCK WATER TANK NUMBER
❑ EROSION CONTROL DAM NUMBER ._
3. WELL LOCATION: COUNTY L)elk OWNER'S WELL DESIGNATION t_IVe5ta-kl, na.t].C....
(0c 10-1 We\6-Co, la? v;;er C.�_l.O 5o.7 `1
(Address) ) (City) �X(State) PP)
St- 1/4 of the..�� 1/4, Sec._ Twp. /� CAN. or S., Range / ❑ E. or W.W. P.M.
Distances from Section Lines Ft. from❑ N. or❑S. Line, Ft. from❑ E. or❑W. Line.
Subdivision Lot Block Filing (Unit)
4. LIVESTOCK TANK OR EROSION CONTROL DAM LOCATION: COUNTY
1/4, Sec. Twp, IIIN. or S., Range.°Wt ❑ E. or❑W. P.M.
5. The above listed owner(s) say(s) that he (they) own the structure described herein.
The existing record is being amended for the following reason(s):
EChange in name of owner. ❑ Change in mailing address. ❑ Correction of location.
6. ! (we) have read the statements made herein, know the contents thereof, and state that they are true
to my (our) knowledge.
[Pursuant to Section 24-4-104 (13)(a) C.R.S., the making of false statements herein constitutes perjury in
the second degree and is punishable as a class 1 misdemeanor.]
Name/Title (Please type or print) Signature Date
D3 j\(ann S. VYnax--}-i n 1/4";,7 /W4�� S- 4-0c
FOR OFFICE USE ONLY
State Engineer By - Date
Court Case No. Div. Co. WD Basin MD Use
4C A
isiiitMEMORAnDU
WilkTo Planning Department Date August 9, 1995
COLORADO
From Pam Smith, Environmental Protection Services
Subject: I.S.D.S. Evaluation for: Martin, William J. & Leslie
Number: 048-95/1205
OWNER: Martin, William J. and Leslie PHONE: (307) 635-2800
MAILING ADDRESS: 68107 Weld County Road 138 Grover CO 80729
CITY STATE ZIP
ADDRESS: ccW-nne (,(S (W --ft
WAWA
CITY STATE ZIP
LEGAL DESCRIPTION: PT: SE4 PT: SE4 SEC: 24 TWN: 12 N RNG: 61 W
SUBDIVISION: N/A LOT: BLK: FLG:
WATER SUPPLY: Private Well RESIDENTIAL TOTAL ACRES: 40
PERMIT ON RECORD: Name: Martin, William/Leslie Permit No. : G-959063 S.O.E. : Yes
System Size: Tank: 1000 gallons Trench: N/A square feet Bed: 200 square feet
Percolation Rate: N/A minutes per inch Soil Type: Suitable
Engineer Design: No Percent Ground Slope: N/A Direction: N/A
The septic system identified above is of sufficient size to accommodate the structure(s) served by
this system.
CURRENT FLOW ADDITIONS PROPOSED TOTAL
Description: House Description: None Description: Mobile Home
Persons: 4 4
Bedrooms: 2 2
Bathrooms: 1 1
Basement Plumbing: No
Neither the County of Weld nor any of its agents or employees undertake or assume any liability to
the owner of the above property, to any purchaser of the above property or to any lending agency
making a loan on the above property or in the report.
This inspection was conducted for the purpose of determining compliance with current regulations
and for detecting health hazards observable at the time of inspection. This does not constitute
a warranty that the system is without flaw or that it will continue to function in the future.
Inspections requested during periods of snow cover and high soil saturation may be of questionable
value to potential buyers due to adverse conditions. Evaluations based on Statements of Existing
(S.O.E. ) relies on information the property owner provides, under oath, indicating current status
of the system and representing to the best of his/her knowledge the system is not failing to
function properly. -
960464
✓G�
t ) z 1. -
'to1C -.64 STATE OF COLORADO °�'-"
o i;,/.1 2 3 1966
DIVISION OF WATER RESOURCES •
Index No 253./ E{tOtl/' 519 OFFICE OF THE STATE ENGINEER COLORADO
WT
SECT
IDWD AA-7 GROUND WATER SECTION STAiE ENGINEER
Use 2-
Registered.. ..2S.:0: LOG AND HISTORY OF WELL
(For State Engineer's Use) PERMIT NO A? lior. WELL LOCATION
gyp, �,'/
Driller � `?1No. ---- A� �C�
�/ y(�}` County
Owner ` 44 IA L�
s.f '/a of_ ..5-I E of Sect.
Street / 6-pM
Twp._-2-� Rge.___ L-lY
Tenant �n � (/�� _
Use of Water --✓V ""' `�""
No. Nerth
On or By C/g�'gC'��l Acres
(dLscriptio of site or land) / II
l , 19 id-s •
Date Started [[S
Date Completed 01Pki ,/
"�(♦
Yield p1.v GPM or --CFS East
West
WELL DESCRIPTION: C�
3 0 ft. Total Depth I) s ft.
Depth to Water -
�s (measured from
� ground surface l.,...
�/___from_o___ ft. to ft.
in. /'
Hole
in from ft. to ft.
Diameter '
in.
from ft. to ft. South
TEST DATA: nn �j e ABOVE DIAGRAM REPRESENTS ONE FULL SEC-
How Tested Pump//or_ Bailed TION. LOCATE WELL ACCURATELY IN SMALL
Date Tested fj*.t.t ,-C , 19(fr Length / hrs. SQUARE REPRESENTING 40 ACRES.
r 3 or
Rate ?.� GPM Drawn Down ft.
If the above is not applicable fill in:
PUMP DATA: -
Outlet Size in. Street
Pump Type N°
Driven by__---_____ HP City or Town
CASING RECORD: or
Plain Casing
/
, Kind - from ft. to ft.
Lot Block— -
Size (0
v Subdivision
Size
Kind— from ___ft. to ft. (include filing or numbed
Size
Kind— from _ft. to_ _ft.
_
TO BE MADE OUT IN QUADRUPLICATE:
Perforated Casing
Original Blue (both sides)and Duplicate Green
Size '°7' _, Kind e' from `, ft. tot ft. Copy must be filed with the State Engineer
within 30 days after well is completed. White
Size Kind from ft. to_ ---ft. copy is for the Owner and Yellow copy for the
Driller. SIGN BLUE C•4: a , a
Size Kind from—_ ft. to—_ ._ ft. -
ens suer I inn ;ICC OCVCDCC CInC
OFFICE OF THE STATE ENGINEER
COLORADO DIVISION OF WATER RESOURCES
821 Centennial Bldg., 1313 Sherman St, Denver, Colorado, 80203
Main No. (303) 866.3581, Records No. (303) 866.3447
CHANGE IN OWNERSHIPIADDRESSILOCATION REQUEST
7
WELL PERMIT N0.�39\ l FROM:COI..C )E „ ""`�"�v
DATE: (p i f /q
pp �
kkeTt o
101 W CP, 11-)8
�.).Ov z. co & -izq
This Change in OwnershiplAddresslLocation form is being returned to you for more complete or a correction of data.
Complete andlor amend as necessary and return as soon as possible. CORRECTIONS ARE TO BE MADE ON THE GWS-11
FORM. PLEASE INITIAL ANY CHANGES YOU MADE TO THE FORM.
1 Complete the well owner name and address. ZI
t this location.
2. Enter or verify he permit number. Our records show permit number
3._ Complete the blanks for the location of the well where checked.
3A._ The location given does not correspond to the location on the well permit Please amend or explain the discrepancy.
(It is possible that a new application for a permit to reflect the constructed location will be necessary.) Our records
indicate that the well is located in the 114 of the 114 of Sec. , Township South or North,
Range East or West, _ P.N. Feet from East or West Section lines.
Feet from North or South and
4._ Complete the blanks for the location of the Livestock or Erosion Control Dam.
5._ Indicate the reasons, either name, address andlor location
6._ The new well owner must sign the document Print or type your name in the first block. If signing as a
representative of a company who owns the well, then your title must also be included in the first block. Sign the
second block and date the last block.
7._ We can not locate the permit for this well with little or no information, please contact your local tax assessor for
the legal description of your property. Names of previous owners, and Subdivision, lot and block number may also
help in the search. Thanks.
Other:
960464
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