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GINS-25 COLORADO aISION OF WATER RESOURIF
818 Centennial Bldg.,13 eman St,Denver,Colorado 80203
(303)8663581
LIC
WELL PERMIT NUMBER 162220 - A
• APPLICANT DIV. 1 W DES. BASIN MD
APPROVED WELL LOCATION
WELD COUNTY •
SE 1/4 SW 1/4 Section 24
SANDRA B RAKOWSKI Township 2 N Range 67 W Sixth P.M.
11467 CR 18 DISTANCES FROM SECTION LINES
FORT LUPTON,CO 80621- 147 Ft.from South Section Line
2504 Ft.from West Section Line
(303)931-7999 UTM COORDINATES(Meters,Zone:13,NAD831
PERMIT TO CONSTRUCT A WELL Easting: 513647 Northing: 4440730
•
ISSUANCE OF THIS PERMIT DOES NOT CONFER A WATER RIGHT
CONDITIONS OF APPROVAL
1) This well shall be used in such a way as to muse no material injury to existing water rights. The issuance of this permit
does not ensure that no injury will occur to another vested water right or preclude another owner of a vested water right from
seeking Set in a civil court action.
2) The construction of this well shall be In compliance with the Water Well Construction Rules 2 CCR 402-2,unless approval
of a variance has been granted by the State Board of Examiners of Water Well Construction and Pump Installation
Contractors In accordance with Rule 18.
3) Approved pursuant to CRS 37-92-602(3)(c)for the relocation of an existing well,permit no.162220. The old well must be
plugged in accordance with Rule 16 of the Water Well Construction Rules within ninety(90)days of completion of the new
wet The enclosed Well Abandonment Report form must be completed and submitted to affirm that the old well was
Plugged.
• 4) The use of ground water from this well is limited to fire protection,ordinary household purposes inside not more than one
single family dwelling(s),the irrigation of not more than 10,000 square-feet of home gardens and lawns,and the watering
of domestic animals and poultry.
5) Production is limited to the alluvium. The depth of this well shall not exceed 60 feet or the depth at which sandstone or
shale is first encountered.
6) The pumping rate of this well shall not exceed 15 GPM.
7) This well shall be constructed not more than 200 feet from the location specified on this permit.
NOTICE:This permit has been approved subject to the following changes:The distances from section lines were
calculated from UTM coordinate values provided with the permit application. You are hereby notified that you have the right
to appeal the issuance of this permit,by filing a written request with this office within sixty(60)days of the date of issuance,
pursuant to the State Administrative Procedures Act.(See Section 24-4-104 through 106,C.R.S.)
APPROVED La.
JMW h>ar State Engineer By
• Receipt No.3612772 DATE ISSUED 01-29-2007 EXPI TION DATE 01.29-2009 ,
2010-0264
(; )til‘c ijEALTH AND ENVIRONMENT
ORG� �REELEY, •COLON PERMIT
555 N. 17TM RADO 60631 • OREANI# #
W I
PHONE: (970)304-6415 ISDS #
FAX: (970) 304-6411
• COLORADO STATEMENT OF EXISTING FOR SEPTIC SYSTEM
2 (PLEASE FILL OUT IN BLACK INK ONLY)
/,
PARCEL# 13 l a b® I o a wort' ,so3) S-36-3132-
PROPERTY OWNER enP1 S a ilia S PHONE NO. (3O3 1 B.Ce 6
MAILING ADDRESS )1%7 woo If { O ` ' icat^ no p D U l
ity State 1 ig1
DESCRIPTION OF BUILDING (ex./house,fm'obrile/modular home,
shop,office) cafe To So t
SITE/LOCATION ADDRESS )0(,-7 LAKE It coif- Lkflar, ( goba 1
(JCity State ,,,,`` i� Zip
LEGAL DESCRIPTION PT PTJW SECTION )1 TOWNSHIPTWV RANGE 67ui
SUBDIVISION LOT BLOCK FILING
CENCUS TRACT LOT SIZE/ACRES t 3
COMMERCIAL YES O RESIDENTIA YES NO
NUMBER OF P RSONrt BASEME PLUIIBING S NO
BEDROOMS BATHROOMS FULL -" 3/4 1/2
WATER SUP' Y PUBLIC YES/�O UTILITY NAME LIhi .I11 16wer/Y'D tkW1L c11 €
PRIVATE YES NO CISTERN YES/ O WELL S iiNO WELL PERMIT#14.222 O
• . SYSTEM SIZE: Septic tank material is constructed ofVbhcfe-T4 and has ) 0 00 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 exists at this time on the parcel of ground identified by the above legal description and further states
that the system isiia.set in good working order and to the best of his/her knowledge*dis not failing to function
properly.
I further understand that any falsification or misrepre nation may result in revocation of any permit granted based
upon this information hereby submitted an legal a ti i n r perjury as provided by law.
C/ild0 0 O 1
lei
DA E O E� yR� �
Subscribed n^�- and sworn to before m
"t '— . day of —SU-AA 194-Ca '
by pent SA\ 1 t\O.S *I •3yri- Ss -Lit Iu I7.Gnt.-I
Witness my hand and officlT %z1tt't4J
eql. 4,0,_�� , o My mission expires:pi IiyCarrrs &stax res,lua5 ma
i-i I -NOHC $ �J 1k1 ➢� `( '1l ltiaL-CO CREDIT UNIC
DATE NOTARY PUBLICS i 1 ' 1 N. HURON ST.
• STATEMENT OF EXISTING Y
ENVIRONMENTAL HEALTH SPECIALIST
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