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COLORADO DIVISION OF WATER RESOURCES Office Use Only Form GWS-45(06/2006)
e DEPARTMENT OF NATURAL RESOURCES
1313 SHERMAN ST, RM 818,DENVER,CO 80203 RECE V ED
phone—info:(303)886-3587 main:(303)866-3581 fax:(303)866-3589
http:I/www.water.state.co.us
GENERAL PURPOSE JUL_ 2 4 2108
Water Well Permit Application
Review instructions on reverse side prior to completing form. wwA'ren•RESOURCES
I ATArr.trinfNFEP
The form must be completed in black or blue Ink or typed. - '
'1.A_pplican_t Information___ _—___.,__l 6.Use Of Well (check_applicable boxes)
Name of applicant _ — Attach a detailed description of uses applied for.
❑industrial 0 Other(describe:
J (—W Sr7Vt5 i.. of i.- __.._ ___.-----.------------ __ ❑Municipal
..MeiIng arloress'---— • i
3 6( G-LENG4G ST- — 0 irrigation
Gay Slate I Zip Code Commercial
DE A/L/ CO _- I` _--3— ._. 7.Well Data(proposed) IL __
Telephone P - -- —1 6-mat(Optional) — Mnust amount to bewitnarawn
µardmum pumping rate gprn
c o3 ) 3'1q. 7666 acre-feet
2.Type Of Application (check applicable boxes) Total depth — —1 ,}a_—�- —
❑Construct new well fl Use existing well LI L7° feet /11---6 H L i_Ai1 SM E+2
0 Replace existing well gr Change or increase use 8.Land On Which Ground Ater Will Be Used
❑Change source(aquifer) 0 Reapplication(expired permit)
❑Other Legal Description(may be provided as an a nt)
3.Refer To(if applicable) ------- LOT 3 RRe co r c≥ E X' "m f)f t o n /0O- ?1R
Well permit* Water Court aria a
' .64ga?— It- t - fise 9'16 .
L Designated Basin Determination a Well name via
i-
4.Location Of Proposed Well (If used for crop irrigation,attach a scaled p that shows Irrigated area.
C«suy _
5 — w rL.Q --- _ 5(.� 1!4 of the NC 1!d '— A.
a Aoles� (Iq.rB. Owner j
Seciion 4 Tavnanip N or S Range E a W—Pnnl9pal Msndian 1�( L Jt^W Tel uC5{rvt(r17 G�E of t
A [ D
63
0[2.
, ( .f' — C. UIt any aherwelts orwater rights used on tNs land:_19)Distance of well from section lines(section lines we typically not property lines)t'
3 U Ft fremgN p S 61-1 Ft.frc4a'E❑W 9.Proposed Well Driller License#(optional):
Fa replacement wets only-dalliance and direction from old wet to new well 10.Signature Of A licant Or Authorized Agent
��ll feet / direction Pp { ) g --
_._1_'��.._ .-.-._-. . _.__...- /- --._---.___-.--- The making of false statements herel constitutes perjury In the second
Well location address(Include City,Slate,Zip) El check If welt address Is seine es In(tam 1. degree,which Is punishable as a cla 1 misdemeanor pursuant to C.R.S.
244-104(13)(a). I have read the sta ements herein,know the contents
rJ thereof and state that they are true to my knowledge.
3 r,W y a. 13Gr eSu I ����� Sign here(Ant be oAyhsersignature) i Dale
Optional: GPS well location Information In UTM format You must check GPS unit for
required settings as follows: '--- -------7-------Dr- --:— � 17/ati/S!�}
Jtf�—
.._..__t--_—___—_____----.— —_.__ --..— ___—._._ Print name Stille
Format must be UTM.
TM I{
❑Zone 12 or O Zone 13 Casting JCS$IW X 1—. 11 Tt_
Units must be Meters Office Use Only
Datum must be NAM Northing - --
Unit must be set to true north USGS, map name DVJR map no Surface ales.
Was GPS untl checked for above? 0 Yll6 Remember to set Datum to NADB3
5. Parcel On Which Well Will Be Located ( Receipt area my
_(PLEASE ATTACH A CURRENT DEED FOR THE SUBJECT PARCEL) J
A. Legal Description(may be provided as an enec ment): I .
(_UT 13 Rewrrjet) E7cenof;°^ Ale' 1 Tans NunLir:3031063
7114/20.8 3:41:27 PM
t;eon avls(L1)
799 t 0— I " L �' i Iota) rr Amt:*100.00
CHECK I
I Chock dumber. 2180
--- — --_— -- __.. _.._ • Chock Amount: $100.00 -' -
B, a or acres In parcel C. Owner WE
�jtrW 7ov,14,..eni 1...L.c. vvR
00. el this be the only wee on this parcel? YES ❑NO(N no—sst other wells) CyyCB
TODD
E. Slate Parcel IQs(options!): MYLAR
2009-0207
Weld Con Environmental Health Services Depa ent OZ_ 0 O 2 3.al/c
1555 N. 17th Avenue
Greeley, CO 80631
Phone: (970) 304-6415
Fax: (970) 304-6411
www.co.weld.co.us
• Septic Permit Application
Application Number: SP-0800131
App Type: Health\Commercial\New\Septic
Applicant Name: BRADLEY CURTIS
LAMP RYNEARSON &ASSOCIATES INC
808 8TH STREET
GREELEY, CO 80631 •
Owner Name: JLW INVESTMENT LLC (45%) &
Parcel#: 079918000021-R1169286
Legal Desc: 7628 PT 18 6 63 S89D31'W 1050' S0D06'E 2057' S69D08'W 313' S0D08'E 25' N69D08'E 721.52'
N16D44'W 318.45' N73D34'E 218.35' S18O49'E 300.93' N69D08'E 491.6' N0D08'W 1700' M/L LB
REC EXEMP RE-748 (.09L) SITUS: WELD 000000000
Site Address: 37525 HIGHWAY 392
App Specific Info:
1/2 Bathrooms 1
3/4 Bathrooms 0
Basement Plumbing No
Full Bathrooms 0
Location Description 37525 HIGHWAY 392
N r of Bedrooms 0
N r of Persons 5
Parcel Acres 44
Private Water Supply Well
Public Water Supply No
Public Water Supply Utility
TERMS AND CONDITIONS
A permit fee,as set by separate ordiance of the Board of Weld County Commissioners,shall be required of applicants for new individual sewage
disposal systems(ISDS),payable at time of application.Permit fees are non-refundable;permit applications are non-transferable.If both a
building permit and an ISDS are issued for the same property and construction is not commenced prior to the expiration date of the building permit,the
ISDS permit shall expire at the same time as the building permit.If an ISDS permit is issued for a property that does not require a building permit,the
ISDS permit shall expire one year after its issuance if construction on the septic system has not commenced.Any change in plans or specifications
after the permit has been issued invalidates the permit unless approval is secured from the Health Officer or his/her designated agent.Expired permits
can be renewed by payment of the permit fee only if:
A.There has been no change in the plans and specifications of the proposed system as set out in the original application or such change is
reviewed and approved by a Division Representative.
B.The surrounding land,its use or zoning has not changed so-as-to cause the original application not to be acceptable under these regulations.
NOTICE
The completeness of this application is conditional upon further mandatory and additional tests and reports as may be required by the Weld County
Department of Public Health and Environment(WCDPHE).The issuance of the permit is subject to such terms and conditions as deemed necessary to
insure compliance with rules and regulations adopted under article 10 title 25,CRS as amended.The applicant certfies that the proposed system will
not be located within 400 feet of a community sewage system.The undersigned certifies that all statements made,information and reports submitted
herewith are,or will be,represented to be a and rrect to the best of his/her knowledge and are designed to be relied on by the WCDPHE for
evaluation for purpo of iss . g the it app. for herein.Applicant further understands that falsification or misrepresentation may result in the
de o t, appli n or rev ation it granted,and in legal action or perjury as provided by law.
r/Appli ant Da e
Weld County Environmental Health Services Department
1555 N. 17th Avenue
Gre
eley,ey, CO 80631 Phone: (970) 304-6415
C Fax: (970) 304-6411
IO
t
COLORADO RECEIPT
July 07, 2008
Application Number: SP-0800131
App Type: Health\Commercial\NeW\Septic
Owner Name: JLW INVESTMENT LLC (45%) &
351 GLENCOE ST
DENVER, CO 80220
Site Address: 37525 HIGHWAY 392
Rcpt# Pmt Type Pmt Method Ref# Pmt Date Amount Cashier Comments
EHS-0800335 Paid Check 1973 07/07/2008 $ 600.00 MSWAIN
Total Payments: $ 600.00
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