HomeMy WebLinkAbout20091462.tiff COLORADO DIVISION OF WATER RESOURCES Office Use Only Form GWS-45(062006)
DEPARTMENT OF NATURAL RESOURCES
ene1313 SHERMAN ST,Rill 518,DENVER,CO 80203
—info:(303)886-3587 main:(303)866-3581 fax(303)886-3589
tdm JMww.water.etate.co.a
GENERAL PURPOSE
Water Well Permit Application
Review rseudlone on hawse aide prior to completing farm.
The form meet be cemM-Yd inat d(or blue ink or typed
1.Applicant Infomtation - If.Utse Of Well(drecIc_app S*.boX9_4 -.--
wn,a//frrc.e (� ._---..-- - -------- Attach a detailed description of uses applied for.
�\ ±cl art_(.�ti:C�i ❑Industrial ❑Otlrr(deeawtie):
-- -_-_. -___ --- .- El Municipal
« (J L% ❑Irrigation��/ C...� �,- . T ern .._�d�-_ __..__—_ Comanemiai
,r '�{ Emee(opaeerl S7 t_�7'' 7.Well Data(proposed)
'• as,nm Ptfl vs ..s sou�rmMWafwn
H7,) Vii"_ I —rams
7„�7I r
/3_ acre-feet
2.Type Of Application(check applicable boxes)
Tee ewe -- ----- i
LL We
iii Construct new wee ❑Use tackling well
❑Replace abaft wee ID Change or inaeaee sae < C': bet
❑Change some(aquifer) 0 Reavp (expired'tomtit) 8.Land On Which Ground Water WIM Be Used
Li Other Lapel Description aim beproecene nnelle rw:
3.Refer To(if applicable) I E-i" n NE L `I%6' Liar
Weep•me, nor Can ewe, I r `��:I g (c� �
/
peeq,meeReinmeaaeeawme -Weem.meel -7L C..
4-Loc* Ol Ptopoeed well (If used for crop ari0+am,raid!a.cred mw nee shoes knpw.c oriel)
r a ,Aaw B. thaw
1a e k� iM �/ [ i.3,...-.,,,u._,,,
�
Ili:�L t„LE� �(_ J ' �/1/ [�L .5\O.r� i
Tonwap /INS EwW PrEcipe Martin .--__ — -. . 7-____
S/
C. ur ee Warne Nen Baba ward narsnu
Kick c-
orrwawr ..am rwa.um rr..bpiraar�eaw«b Knit
a
ft from gat❑S ran❑E Kw S.Proposed Weil Driller License 1Koptionaq.
For replacement eels sly-bin end Anne ara alewee m cer wet 10.Signature Of Applicant(s)Or Authorized Agent
feet direction
�r The making of false statements herein constitutes perjury)n 8s second
Wee leaden a aadre.dg.era 2144)) Qararr..taams.seem.es In Rem 1. degree,which Is punishable as a date 1 misdemeanor pursuant to C.R.S.
i(y 0 sins j C(t, 24-4-104(13Xa). I haw read 8s statements M(Nn.know the contents
r thereof and state that they are true to my know.Mdge._.-- _----
.._ ./L .4P-
�h ` CC 4. -- ... Sion Iwo MSS likrakay • or.
Onion BPS watt lee Wiornolc i in UM forme You mat chock GPS mil air
reveled mango slabs
rtrrlr _. HYemnme w.12 Office Use Only
a.aAOes L _ —_--
UM boon norm y OROS map naps CMm rnapro. Sung eke.
ere e b El 1 fat ✓i
.Parcel On kh Weil WIM Located Receipt ama day
_-(PLEASE ATTACH A CURREIIT DEED FOR THE SUBJECT PARCEL) _
A Legal Description tombs pot n ran Madmen*
Sty_ i( I S�:` J\L-t. C
t.ui 0 1;1: `f4a C.
a It ones In wall C. ,Oman 0, WE
MINIS tha=RAN n this parcel?RYES ONO Rine-IN Mar NIB CWCB
repo 2009-1462
E. -----
E. San of(cola* uvtAR I
Sacs OW 1M BA MD
Colorado Division of Water Resources Application Receipt No.
1313 Sherman St.Rm.818 `
Denver.CO 80203 Applicant's Name: E.c. ;:c •�
1303)866-3581
http://water.state.co.us/default.htm
• COMMERCIAL DRINKING AND SANITARY WELL WORKSHEET
Name and Type of Business , Id li,t- - tit., : .i r i ,/'n-=.
1. Is this application for a new well?
- Yes
No If no, is this application for a change of use for an existing well?
Yes Permit Number of well (if applicable)
_
No For wells used for drinking and sanitary purposes prior to May 8, 1972, a field
_
inspection of the well to verify historic uses is required. See form GWS-12
Registration of Existing Well for further information.
2. Is another source of water available to the property? (i.e. water district or another well)
Yes If yes, indicate what this other'source is (name of water district or well permit number)
f.
�- No
3. Type of disposal system:
X. Septic tank/absorption leach field
Central System (district name:)
Vault (location sewage hauled to:)
Other (attach copy of engineering design)
4. Water Demand Calculations (for average factors for water demand see below)
Employees
Number of X Number of Gallons X Number of Days = Gallons per Year
• Employees per Employee per Day Employee Works per Year
X " `,,,,'L -
- X /'. - A
Customers
I Number of X Number of Gallons X Number of Days Business = Gallons per Year
I Customers per Day per Customer is Open per Year
X X = ( ,:. , , B
Other Uses(Note: No uses outside of the bulldog would be permitted for these types of wells)
Type of Use X Gallons per Use per X Days per Year = Gallons per Year
Day
-------_ X -._.. X • _ _ - _.._. . C
Total amount of water required:
= Gallons per Year
(A+B+C)
= /
For wells used for commercial drinking and sanitary purposes on and after May 8. 1972, the total water demand cannot exceed
108.800 gallons 11/3 of an acre-foot)per year.
For wells used for commercial drinking and sanitary purposes prior to May 8, 1972,the total water demand cannot exceed
325,900 gallons(1 acre-foot)per year.
General Guidelines for Water Demand in Gallons per Day
Day Workers at Offices- 15 gallons/person/day
Food Service Establishments(with toilet and kitchen wastes)-10 gallons/patron/day
Churches(does not include food service)-5 gallons/seat/day
Overnight Lodging-50 gallons/customer/day ,
On-Site Proprietor of Overnight Lodging(i.e.on-site owner of a Bed&Breakfast)-80 gallons/person/day
• Additional water demand figures may be obtained from a private water consultant or from a technical reference on this subject. GWS-57
11/99
Hello