HomeMy WebLinkAbout20040237.tiff .-
Wit) 1, (i, COLORADO DIVISION OF WATER RESOURCES
300 Columbine Bldg., 1845 Su nnt','a St., Denver, Calorado 80203
PERMIT APPLICATION FORM
Application Rust
be complete where ( I A PERMIT TO USE GROUND WATER /'r n' (0l
applicable. Type or (X ) A PERMIT TO CONSTRUCT A WELL r' ' �� Q 1Y�V �' !,
print in BLACK FOR: j>4A PERMIT TO INSTALL A PUMP t`���
INK. No overstrikes •
76
or erasures unless ( ) REPLACEMENT FOR NO. O117 r
initialed ( I OTHER
ES
WATER COURT CASE NO. WptEa �S nE g
Vic-
(1) APPLICANT - mailing address FOR OFFICE USE ONLY: DO NOT WRITE_IN THIS COLUMN .f,-1
NAME inILdb ' . n 52
" 1rnnricin Products Conmy Receipt No. 752 J 1 . .
STREET 13100 Mast 39th Avenue
Basin _. Dist.
CITY Denver, Colorado °x239
(State) (Zeal CONDITIONS OF APPROVAL
TELEPHONE NO_ _321,.6.710 This well shall be used in such a way as to cause
no material injury to existing water rights. The
(2) LOCATION OF PROPOSED WELL issuance of the permit does not assure the applicant
that no injury will occur to another vested water
right or preclude another owner of a vested water
County WI rl • right from seeking relief in a civil court action.
' : of theTi :, Section 2 GROUND WATER PRODUCTION SHALL BE LIMITED TO THE
nt' IARI -FOX HIT,TS AQUIFER ONLY WHICH IS EQUIVALEN
Twp IN Rng. 657 6:rY pM. TO THE INTERVAL FROM 700 T0"970 FEET ON THE
" s °t' ELECTRIC LOG OF WELL PERMIT NO. 21010-F IN 8.35,
(3) WATER USE AND WELL DATA T. 2N, R. 65W. PLAIN CASING MUST BE INSTALLED
AND PROPERLY SEALED TO PREVENT PRODUCTION OF WATE
Proposed maximum pumping rate(gpm) 15 FROM OTHER INTERVALS.
AVERAGE ANNUAL APPROPRIATIONS FROM THIS WELL SHAT
Average annual amount of ground water 1 1/2 NOT EXCEED 1.17 ACRE-FT. TOTALIZING FLOW METER
to be appropriated (acre-feed. MUST BE INSTALLED ON THE WELL DISCHARGE WHEN THE
Number of acres to be irrigated: None • WATER IS PUT TO BENEFICIAL USE. DIVERSION RECORD
SHALL BE SUBMITTED TO THE DIV. OF WATER RESOURCE;
Proposed total depth (feet): ^5(1 f..nt UPON REQUEST.
THE ENTIRE LENGTH OF TIE OPEN HOLE SHALL BE
Aquifer ground water is to be obtained from: ELECTRIC SURVEYED AND A COPY OF THE LOGS MUST BE
SUBMIITE.D TO THE DIVISION OF WATER RESOURCES. t
Owner's well designation
GROUND WATER TO BE USED FOR:
1 1 HOUSEHOLD USE ONLY - no irrigation (0)
( 1 DOMESTIC (1) ( I INDUSTRIAL (5) •
( ) LIVESTOCK (21 ( I IRRIGATION (6)
(K4 COMMERCIAL (4) ( A4MUNICIPAL (8)
( I OTHER (9) APPLICATION APPROVED
DETAIL THE USE ON BACK IN (11) ^
PE8MITNUMBER 2.1904(4) DRILLER DE
lr 16 19/5
DATE ISSUED L U
Name Holden and Holden n C n 1977
Box 188 EXPIRATION DATE _
Street - •
/. s
Hudson Colorado 30642. r► ��._ J
City
(State) ATE EN 1 y.' ) 2004-0237
(Zip)
536-4131 1 BY
Telephone No. Lit. No. I
I
,
(5) THE LOCATION OF THE PROPOSED WELL :lad tit: ,,r,•,,on (6) TI IE WELL MOST BE LOCATED BELOW
whlr.h thtr :v,tlr•t sv:(I he t,•,,:<l mulct be inihc.nl,.11 tom the mJt.ulr,:,,, Ivtlnw. by 4ir,.ltr,r. •,hum u•, il•„i I,l„;.
Use the CENTER SEC]ION (i Sia:lion, 6.10 acres) for the well location.
•
•
. - . _t. j — �- tt burn _rnlf.ij_--__ tiac. Imr
1 n„„tl n, ...moth)
1 "'-. .rr: :I:•MILE.5280 FEET
.fl. from sec. line
_.
11 .�
T -4- 1- - J —4....- —(CJSf Q, west)•
• LOT _-.__.__BLOCK FILING ar
(. _ NORT H SECTION LINE — T I„ I S11801 VISION�,_ __
t Y �'
(7) TRACT ON WHICH WELL WILL BE
NORTHl w� - LOCATED Owner. .TJ 1
u r In •— .1.
1 y No. of acres IRLnr: Will this be
Z -i
O to
i the only well on this tract'• YC`S
w -+ - - �-<
i °z (8) PROPOSED CASING PROGRAM
to) f- I Plain Casing
4— 3•- — --I- - -•- - - z
I - 6 —in. from () _ ft. to -.'
i I — ft.
•
• t, 1.
- I '. in. Irons 1r) ft. to I' • ' ft.
t SOUTH SECTION LINE -i Perforated casing
___—.___in. from f' _ft. to `;JO ft.
+ -i. # * r• -} 1 4
ut, from ft. to— ft.
i i (9) FOR REPLACEMEPJZ,WELLSgived,stance
.... .1.- - --)•- -i._. __. + _ -i-. - and direction from old well and plans for plugging
'_ r it:
The scale of the diagram is 2 inches - 1 mile
Each small square represents 40 acres. '�'-
-
WATER EQUIVALENTS TABLE (Rounded Figures( ^--
An acre-foot covers I acre of land 1 foot been
I cubic foot per second fcfsl . .449 gallons Per mmule (ypml
-
A family or 5 will require approximately 1 acre-foot of water per year.
1 acre-foot . . . 43,560 cubic feet. .325,900 gallons.
1,000 gpm pumped continuously fur one day produces 4.42 acre-feet.
(10) LAND ON WHICH GROUND WATER WILL BE USED:
Owner is);
JV 1 r?bn AmericanPra:lncts Company
C No. of acres:_
Legal a chp`t,on• fir} 1/'(• £Ct on •? 1P. i- r n
(11) DETAILED DESCRIPTION of the use of ground water: Household use ancp^lpmestic wells must indicate type of
disposal system to be used.
f
;x•1 1.t 1
•eotic t:Ink and leach fielrI, Low income ..ton..;-i_n.;, three mor.thn of year,
20 unit , 5 people each. Total 100 neonle- 20 kitchen- 2 commin i.
ty bath
(12) OTHER WATER RIQHTS used on this land, including wells. Give Registration arid >'.'ater Court Case Numbers. room.
Type or right Used for (purpose)
Description of land on which used
Gone
(13) THE APPLICANT(S) STATES THAT THE INFORMATION SET FORTH HEREON IS
TRUE TO THE BEST OF rs K OWLEDGE.
J -
(\ ,,
SIGNATURE OF APPLICANTIS1
�. 4..4,.f-7,-._i---,-!/[2a_ i-:ks..0.c !�'
1
MAY-23-2003 FRI 11 :52 AM ErR0N HEALTH SERVICES 970304Fr`1 P. 06
STATE OF COLORADO
Bill Owens,Governor
Jane E.Norton,Executive Director • O4 �gt,
�� .,.
Dedicated to protecting and improving the health and environment of the people of Colorado
4300 Cherry Creek Dr.S. Laboratory and Radiation Services Division * i G.:1 •,*
Denver,Colorado 80246-1530 8100 Lowry Blvd, 99_ r
Phone(303)692-2000 Denver,Colorado 80230-6928
TDD Line 13033 691-7700 (303)692-3090 Colorado Department
Located in Glendale,ColoraeP
Health
http.Wwww.cdphe.state.co.us and Environment
September 9, 2002
PWSID# 162360
Luisa Chavez, Owner
Hudson Labor Camp
22185 Hwy 52
Hudson CO 80642
RE: REQUIREMENTS for a Community Drinking Water System,
Ground Water Source,Weld County
Dear Ms. Chavez: .
Information supplied to this office indicates that the above named water system serves water to
30 year round residents. The Colorado Primary Drinking Water Regulations (CPDWR) define a
community water system as one that "supplies water to 25 year-round residents or at least 15
service connections used by year-round residents." This system is, therefore, subject to the laws
set forth by the above regulations.
The Public Water System Identification number(PWSID#) assigned to the above named water
system is 162360. This number is used to identify your system and should be used on all
samples and correspondence pertaining to your drinking water system.
Public drinking water systems that serve 25 to 1000 people must submit a minimum of one
bacteriological water sample(s)per month from their distribution system. Sampling must begin
in October 2002.
Public water systems must also have their treated water analyzed for the following chemical
analyses:
NITRATE/NITRITE as NITROGEN
INORGANIC
RADIOLOGICAL
ORGANIC
�- LEAD AND COPPER
See the enclosed schedule for your 2002 monitoring regnirementa. -- lOe, fiLz0.4-edit ��i
• MAY-23-2003 FRI 11 52 AM E'`".R0N HEALTH SERVICES 970304E-441 P. 07
Failure to submit any of the required samples is a violation of the CPDWR and may lead to legal
action.
If you have any questions please call me at(303) 692-3543.
Sincerely,
Stitt 41
Erica Kannely
Engineering Physical Sciences Technician
Compliance Monitoring &Data Management Unit
WATER QUALITY CONTROL DIVISION
cc: Weld County Environmental Health Department
Betsy Deaver, Certification Board, CDPI-M
Dennis Pontius,District Engineer, CDPHE
Dave Rogers,Lead& Copper Program, CDPHE
DW File, Section 5
ENCLOSURE
S:IWP\REQICOMM_GRD.REQ-Revised 11/95
MAY-23-2003 FRI 11 :51 AM ;+4VIR0N HEALTH SERVICES 97030412911 P. 04
...SD COUNTY DEPARTMENT OF PUBLIC SOE# ..A` ,-- L-Jv\--' ! Li
44ttlei;
HEALTH AND ENVIRONMENT REP PERMIT#
1555 N. 17 AVENUE REPAIR#
GREELEY, COLORADO 80631 ORG
LOAN it
r imige PHONE: (970) 304-6415ISDS#
FAX: 304-6411(970)
COLORADO STATEMENT OF EXISTING FOR SEPTIC SYSTEM
(PLEASE FILL OUT IN BLACK INKS (ONLY)
PARCEL NO.-/..L . 4._... , 7.: ) , /' 17bb 003^.
(. L/PROPERTY OWNER �� "�S �f �I���/!r'c ,(=Z- PHONE NO.��� ,, )55(.- V
MAILING ADDRESS J 9?v ‘ 6 ? //ri to yl ro
City State Zip.
DESCRIPTION OF BUILDING(ex house,mobile/modular home,shop,offic ) A/`I', , i U- 5� 1 in
SITE/LOCATION ADDRESS R2 I Qtr (-7w, 52 �� d�xd C,.) 9a,�`.�z-
City State Zip
��
LEGAL DESCRIPTION PT PT SECTION TOWNSHIP 1 RANGE L )
SUBDIVISION LOT BLOCK FILING
CENCUS TRACT LOT SIZE/ACRES y A -e f
COMMERCIAL YES/NO RESIDENTIAL _S NO
NUMBER OF PERSONS/(J BASEMENT PLUMBING YES
BEDROOMS/0I OOMS-FULL VT 3/4 1/2
WATER SUP LY-PURT.IC YES N
PRIVATE YES/NO WELL 1 S v0 CISTERN YES/NO WEII./CISTERN#
SYSTEM SIZE: Septic tank material is constructed of C.e//2c-n4 and has 206) gallons capacity.
FIELD: Trench square feet or Bed square feet YEAR INSTALLED
You are required to draw a diagram of the system on the reverse side of this form in black ink only and indicate
location,length,width,and distance from the dwelling.
The undersigned property owner hereby certifies that the above described septic system is in fact installed,as
described,and sts at this time on the.parcel of ground identified by the above legal d rition and further states
that the sys i not in good working order and to the best of his/her knowledge is/' not Ring to function properly.
I further understand that any falsification or misrepresentation may result in revocation of any permit granted based
upon this information hereby submitted and in legal action for perjury as rovided by law.
F-5° '—d 2 G . /
DATE OWNER SIGNATURE
Subscribed and sworn to before me this, _ .3&. day of .42S-,,S., a.S0, .•M`eie
By err. `°L� � G ; ao1AltY .!
Witness my hand and official seaL My commission 'r
r expires lJi�.�"
9 ,3v - o?Da fit+ fri.,-412.)
/� /u �� 'c f• y j� PU,,,,,,.'f�DATE NOTARY PUBLIC s'r.ir'llf OF GO."
STATEMENT OF EXISTING INSPECTED&REVIEWED BY
ENVIRONMENTAL HEALTH SPECIALIST DATE
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