HomeMy WebLinkAbout20052385.tiff qt. H. c0U5 IL:19Vhl MU. J4d t
Fkriu-ut wad me-OIVISICN OF JILTER RESOURCES 3038662223 _. T-I04 P.02/D4 F-00d
MRJ-5 fib STATE OF COLORADO DIUISIpN OF WATER RESOURCES me(r�'� o
•
CJ A PERMIT USE GROUND WATER AUG24toll
• L7 A PERMIT.TD-CONSTRUCT A WELL 'ie
APPLICATION FOR: 3491 REPLACEMENT FOR N0, y_
C7 A pERNIT TO 1NtTALL A PMAIp ...,,i, ENt
.C7 OTHER
PRINT DR TY LOCATION OP WELL
APPLICANT Alpjry R• lounstoa COUNTY WAl el. .
Street Address 3022 - 26tkk'9tr4et SDd >L, S3 t, sec, 2v
City E. State (tnnely. Colorado 80631 T .16 , FG RV & P.N.
Street or
Use of ground water 4ntveatio Lot E Meek
Owner of land on which well Cjxy.or
is located sirup Subdivision ----
Number of acres
to De Irrigated -r-i., Ground Water Basin ___-
Legal description of ,Mater Management
irrlgetea land ... .. 'District
ether water rights on
i lend
____
LOCATE WELL ON THE BACK OP TN L SHEET
Owner of Irrigated
land Drillaryotpmt A 2il1T,TrLI No.1
Aquifer(s) ground water is to he obtained Driller's P. O. IIox 186
from ' Address Rum nnn), r ••a e mail?
Storage capacity .._.. AF tY .(ucti'fl •
{ .� .
1 TN` P A p scant
THE FOLLOWING TWO FIGURES ARE M71XIMUMS AND
CANNOT SE EXCEEDED IN FINAL USE. COWortlONS DF APPROVAL
-
MAXIMUM PUMPING RATE 20 GPM
AVERAGE ANNUAL AMOUNT OF GROUND WATER TO
BE APPROPRIATED ,... - Acre-Feet
ESTIMATED WELL DATA
Anticipated start of drilling R-17- 39i .
Anticipated start of use amelnriin+rlr 1SW
mole Diameter: APPLICATl ON APPROVED;
n in. from 1- ft. to 200 ft. VALID FOR OWE (1) YEAR AFTER DATE ISSUED
in. from ft. to ft. UNLESS EXTENDED FOR GOOD CAUSE SHOWN TO
THE ISSUING ASENCY C
C sinng: PERMIT NO. 42685 CONDITIONAL T
rlaln L in. frail O ft. to 16Oft. • • I
in. from ft. to , ft. DATE Issoon ig- E 11970
Pert'. _ O7 in. from 160 ft. to 200ft.
41 n. Fran fz. to ft. STATE EMGIN' or NAiRMAN OROuNb
ESTIMATED PUMP DATA WATER COMMISSION
outlet 5y_ � e I
TypetaurnrsibleNP S Size 1?"
I
APPLICATION MUST SE COMPLETED IATISFACTORILY RJFgRF ACCEPTANCE 200' ?°111:1121OOt East
(OVER)
2005-2385
gU9Pa7 R � �
. Loan- /0,5--co '
, SANITA.(12P; :7-..!.'r".;0N
UN 2 1990
STATEMENT OF.EXISTING SEPTIC SYSTEM
(PLEASE FILL OUT IN INK) MU COMVIM DEPT.
OWNER OF RECORD: -i e (-7,9-7„,./ "0 Phone: 390 — 00 (r,/
MAILING: ADDRESS: clYag 4 • O /^ ci ace /e0. 14 e /P ip On g'( ej s y
r/�// / City /r State Zip
Zip /
SITE ADDRESS: // K,,b 3 �.h /� E , e� GA St/J. 6.70 8 DO y-v
'`� ) City State Zip
LEGAL DE',SCRIPTION_. PT Cc PT Section ,2l"/ Township //V Range /1.�� ,
SUBDIVISION LOT BLOCK FILING
r . / J--.
q
NUMBER. OF PEOPLE: Bedro ms: 3 Bathrooms: ►/ 'Water Supply. frr5//C LG,�c//
RESIDENTIAL OR COMMERCIAL: SI f,p�'jt7;:d / Lot Size: I�
fj. 7 Acres
SYSTEM-SIZE: Tank is Constructed of CUnCYCtC and has /(/v0 gals capacity
(material) g// 4/1Pt1
— IELD: Bed ,,,)5, or tench .6ieo sq. ft. Date System Installed: /70A,
A'
You are required to draw a diagram of the system on the reverse side of this
form and indicate position, 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 exist$ at this time on the parcel of ground identified by the above legal description and further states_
chat the system is in good working order and to the best of his/her knowledge is not
failing 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 provided by law. -
i
. -6T21-1,4 ! . Ad
Date !7 ex
Subscribed d sworn to before me this G'G pay of (i...44.-.74.-e--
'/; ' . 19/Q
by —_
Witness myrha3ad and official seal. My commission expires -s2 - 9`y`
Date .. /7� Nooftaary Puhuic / '/
STATEMENT OF EXISTING REVIEWED BY //7t-1-&--, b (/OA,�t.�' 4,2 /� .f�' tie
Hello