HomeMy WebLinkAbout20010798 Jf;N-1N-01 03 : 55 -'M P. 02
COLORADO DIVISION OF WATER RESOIJnCES
DEPARTMENT OF NATURAL,,RESOURCES
1313 SHERMAN ST.,RM.818,DENVER CO 80203
phone -Info: (303) 886-3587 main: (303) 886.3681
RESIDENTIAL *Note:Yaw may else sae Vw form to apply ter attack Watseka) Water Well Permit Application
Review Instructions prior to completing form Must be completed in black Ink or tvped
1.APPLICANT INFORMATION 6. USE OF WELL(cheek apptopdete crow or entries)Nord glare
See tinnier:*to detennkte mete)for with you nary qualify—
d \ I Dana t ra Qtr 'c. CIA.Ordinary household use in one single-farttify dwellingM.a v war... 7 WS otRakb ass)
B.Ordinary household use M 1 to 3 single-ramdy
,2110 55 Orlparls ( "Jr &range:
k� N bar of dwSlttgs:
rum//"//.���M //11 // D�`� Home gerdenAawtt lrigaton.not to exceed 1 sae:
`-Vr r/r r I e rCe LA ty Co eco22 wee Intpnted l llric (ii so.ft.ai acre
T 30 (05 ' /67 / (o Domestic animal watering —con-commercial,
2.TYPE OF APPLICATION (check applicable boxies)) AEC. Livestock watering(on teem erbehhengwowmnl
X Construct new'well O Use existing well 7.WELL DATA
O Replace existing well D Change/Increase Use ""ban rams"'e' Arab.amuse el u"enhs..m
O Mango Mourne)aquifer Ci ReapprteationG caaa,.eng /5 awn 3 acre-feet
CI Other T dell �y lathe
3.REFER TO (if applicable)o P00 feet
Weer
oast es a Pee°h• 8.TYPE OF RESIDENTIAL SEWAGE SYSTEM
W'Septic tank /absorption leach field
Vete a Monitoring hole saeawvardoawnt a Ci Central system
-VE- MH- District name:
wa ire we O Vault
Location sewage to be hauled to:
4. LOCATION OF WELL O Other(attach copy of enpiaeedng design)
Cprany cue tedowrt.r Quarter 9. PROPOSED WELL DRILLER options)
1 law newer
Section Tu same
m h@ N or a Re E or w Primer Mown G Ib Yti r It I tars
co 2 lir a (,p(, a Lt" P M 10. SIGNATURE of applicant(s) or authorized agent
Distance of well Iroe,faction Free The making of false statements herein constitutes poker400 „stoma*. G s 400 w hem Ira OW m the second degree,which is punishable as a class 1 mis-
srldstracfrpt o C.FLS. 244-1040'rakes .k"oi°�in G (‘to demeanor pursuant the statements herein, know the contents )thereof and state
Ns,�aen.e Iva one-an end ae.Sen hem old well a:ew wet that they are true to my knowledge.
feet direction "'1e; p^�oa
5.TRACT ON WHICH WELL WILL BE LOCATED
A. You suet cheek ems of the following-see irtsduedpr)s Taft
CISub.yision: Name 'lDatta IOC)
Lot no. Block no. fling/Unit OPTIONAL INFORMATION /
iii Canty exemption (attach oopy of county seproval h survey) a°oe n""w ie j fl* few r • wr«e Mr.
NameMo. Tract no.
❑ Mining claim (attach copy of deed or sw+syi Office Use Only
; memo. DIV
Other 1 h Waal description to epplenten) —
6a a'6l ached Co
—,. S. STATE PARCEL EXHIBIT
IDS (epdenall. WD
C. .ores W vac, 0. Are you the owner et chic propnty? .a ^w
Cf]J ,� 71 ES ❑ NO (if no - see inat uctionc,I
DE
E Will this be the only well on this tract?
.NYE5 O NO (if other wells ate on this tract-see instructional U 2001-0798
Septic Information
We just contracted with an Engineering Firm to perform our Soils and Perc test in order
for the Septic Application to be turned in. The application will be turned in in the next
couple of weeks after they have performed the appropriate tests.
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