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Home My WebLink About20223049.tiffForm No. GWS-1 f 4/99 STATE OF COLORADO OFFICE OF THE STATE ENGINEER 818 Centennial Bldg., 1313 Sherman St, Denver, CO 80203 (303) 866-3581 Fax (303) 886-3589 For Office Use Only r „ r _r- x� ' APR 2 8 2000 vv,Li,..:. ,":: cc., c., Irt � s CHANGE IN OWNERSHIP/ADDRESS CORRECTION OF THE WELL LOCATION Insert the Well Permit Number / il los l r k . Name. address and-Qhcne of the person claiming ownerskiip_ol g well: NAM(S) Mailing Address City, St. Zip Phone () Mr. Joseph Y. Nakagawa mm 2102 Cherry Ave. If your well has an absolute water right, decreed by the court and the well is not registered with the State Engineer, Enter the Water Court Case Number / Civil Action Number and well number as decreed. ._.. _.. Greeley, CO 80631 _3cjqr_. This form is filed by the named individual/entity claiming that they are the owner of the well permitted as referenced above_ This filing is made pursuant to C.R.S- 37-90-143. WELL LOCATION: County Owner's Well Designation (Address) (City ) ff fX11/4 of theit1/4, Sec. Twp. N N. or O S., Range b❑ E. (State) (Zip) or WW., la_ P.M. O E. or W. Line. , Filing/Unit _IL, Distance from Section Lines 5-0 Ft. From 0 N. orX S„ fr..5-. Ft. From ... Subdivision Name Lot , Block The above amended 0 Correction May 17, listed owner(s) say(s) that he, she for the following reasons: Change (they) own the well deoggibed herein. The existing record is being in name of owner Al.Change in mailing address permitted prior to May 8, 1972 and non-exempt wells permitted after for furtherinformation regarding correction of the well location. of location for exempt wells 1965, Please see the reverse side I (we) claim and say that I (we) (are) the owner(s) of the well described above and that the commencement of extraction of ground water from this well, lawfully made under the well permit; occurred on the date indicated, and that the statements made herein are true to my (our) knowledge. Please print the Signer's Name & Title nature(s) the n n r Date 1 IV C Mr_ Joseph Y. Nakagawa 2102 Cherry Ave. Greeley, CO 80631 1 It is the responsibility of the new owner of this well to complete and sign the form_ Signatures of agents are acceptable if an original letter of agency signed by the owner is attached to the form upon its receipt. For Ofticc Usc Only ACCEPTED AS A CHANGE IN OWNERSHIP AND/OR MAILING ADDRESS. 7/1:te Z . , State Engineer By • Date Almost 2, 1999 INSTRUCTIONS CHANGE OWNERSHIP -ADDRESS LOCATION CORRECTION FORM' NO FEE IS REQUIRED The form must be typewritten or printed in BLACK INK. Initial and date any changes you make on the form. THIS FORM MAY BE REPRODUCED BY PHOTOCOPYING OR WORD PROCESSING MEANS. INCOMPLETE FORMS WILL BE RETURNED. Be sure to include the well permit number in the space provided at the top of the form. The form is to be completed by the new owner (the i divi ual,, c__om any ar entity claiming oy�rnerski of the well). Print the new owner's name and include the mailing address and phone number. Complete the well location information. If the address of the well location is different than the mailing address of the owner, include the address where the well is located. The actual well location must include '/;, '/4, Section, Township and Range. Check the aspropriate boxes for North or South. and East or West directions. Complete the Subdivision, Lot, Block and Filing information, if applicable. Indicate in the appropriate boxes if the form is submitted to change the ownership and/or address, or both. The individual, company or entity claiming ownership of the well must sign the form. If you are signing as a representative of a company who owns the well, then your title must also be included in the first block. Sign the second block and date the last block. USE THIS FORM TO CORRECT THE LOCATION OF YOUR WELL IF: A. Your well was permitted,. registered, or first used prior to May 8, 1972 for ordinary household purposes in up to three single-family dwellings, fire protection, the watering of poultry, domestic animals, and livestock on farms and ranches and the irrigation of not over one acre of home gardens and lawns. B. Your well is not of the type described in A above, but was permitted or registered prior to May 17, 1965. Inside the Designated Ground Water Basins, other procedures and publication may be required. C. Your well was decreed by Th Water aloft for the correct (ovation. IN ALL OTHER CASES USE FORM GWS-42 (CORRECTION OF WELL LOCATION FORM). If you have questions, contact the Denver or the Division Office where your well is located. Division 1 810.9t St. 2'd Floor Greeley, CO 80631 (970) 352-8712 Fax (970) 391.1816 Division 2 310 E. Abriendo Ave Ste B Pueblo, CO 81004 (719) 542-3368 Fax (719) 544-0800 Division 3 422 4th St Alamosa, CO 81101 (719) 589-6683 Fax (719) 589-6685 Division 4 1540 E. Niagara Montorse, CO 81402 (970) 249-6622 Fax (970) 249-8728 Division 5 60633 U.S. Hwy 6 & 24 Glenwood Spgs., CO 81801 (970) 945-5665 Fax (970) 945-$741 Division 6 1120 S. Lincoln Ave. Ste 101 Steamboat Spgs, CO 80477 (970) 879-0272 Fax (970) 879-1070 Division 7 . 1474 Main Ave. Ste. 211 Durango, CO 81302 (970) 247-1845 Fax (970) 866-5417 Denver Office 1313 Sherman St. Rm. 818 Denver, CO 80203 (303) 866-3581 Fax (303) 866-3589 WRJ-7,_! kiiCommission expires: / COLORADO DIVISION OF WATER RESOURCES TYPE pR c, �[J 818 Centennial Bldg.,1313 Sherman St. PRINT IN BLACK INK. COyFY OF ACCEPTED Denver, Colorado 80203 STATEMENT MAILED ON REQUEST STATE OF COLORADO COUNTY OF .-. V�I7 SS. RECEIVED DEC 1 91979 NAM RESOURCES AFFIO� STATEMENT OF BENEFICIAL USE OF GROUND WATER AMENDMENT OF EXISTING RECORD LATE REGISTRATION PERMIT NUMBER P I212_O LOCATION OF WELL THE AFFIANT(S) eililitLEM K- fu 1' OS H-1 whose mailing y } address is 1 G. e r A of Ili., T -- 1�. Section 45,.,.x. City -...... e4 0 (il.Te) 80 4.3_1_ Twp. S Al _ R,r� fps- L _ C P M 4F OR WF being duly sworn upon oath, deposes and says that he (they) is (ore) the owner(s) of the well described hereon; the well is located as described above, at distances of AoSli04 feet from the _tio- section line and ' 6„__ feet from the i.e.; 4 o. 5O111?!) -k C'd f section line; water from this well was first applied to a beneficial use for the purpose(s) described herein on the 2.r tEasr 4R wfs+1 day of 420- 19 1-3 ; the maximum sustained pumping rate of the well is ...Z(.3 gallons per minute, the pumping rate claimed hereby is .._ O _-- gallons per minute; the total depth of the well is 0.,___feet; the average annual amount of water to be diverted is acre-feet; for which claim is hereby made for Corn onel e i purpose(s); the legal description of the land on which the water from this well is used is 14) df e l� Yy J . lc 7-2 /a 5 4f 2A1la :r--11 .lh y ?tiffs e 43 o which f/ acrel' are irrigated and which is illustrated on the map on the reverse side of this form; that this well was completed in compliance with the permit approved therefor; this statement of beneficial use of ground water is filed in compliance with law-; he (they) has (have) read the statements made hereon; knows the content thereof; and that the same are true of his (their) knowledge. -(COM LETE REVERSE SIDE OF THIS FORM) Signatures raid M. Miyosh(Agent) Subscribed and sworn «� to before me on this _ 1 ! day of My Conrniggion Expires NOTARr usLEC. , 19 A ACCEPTE-D FOR FILING BY THE STATE ENGINEER OF COLORADO ----PSI.RSUANT TO THE FOLLOWING CONDITIONS; FOR OFFICE USE ONLY Court Case r'ta. P; iOr. Mn. Di w, Cty, Well Use Dist. eosin Mon. pit — :),ATE B Well drilled by e f c • Permanent Pump installed by S 4 M Lic. No. .5/ Lic. No, Meter Serial No. ❑ Flow Meter Date Installed 4/-19.7.3 Owner of land on which water is being used C.i- B 1.- 4/1 4j4..f�.,� �1 r 5111 THE LOCATION OF THE WELL MUST BE SHOWN AND FOR LARGE CAPACITY IRRIGATION WELLS THE AREA ON WHICH THE WATER IS USED MUST BE SHADED OR CROSS -HATCHED ON THE DIAGRAM BELOW. NORTH 1 This diagram represents nine (9) sections, Use the CENTER SQUARE (one section) to indicate the location of the well, if possible. + — - + - + 1 + — I + + — + + — + + + — + NORTH SECTION LIf'IE� + — rn + i1yl, ��' 7-71rn z — r. r yr m_ + -- -I- 7, + - w + - - - T BOUT SECTION LI E .... — _± _. ..-T +.. — _ + + . — + - TI -E SCALE OF THE DIAGRAM IS TWO INc11 5 Ll'A'LS ONE -MIL E + I + — -F - + + + - + 1 Mile----'- WATER (WHITE AND PINK COPY TO BE FILED WITH THE STATE ENGINEER PINK COPY WILL BE RETURNED TO OWNER) 'THIS FORM MUST BE SUeMITTE❑ WlTHIN&0 DAYS OF COMPLETION OF THE WORK DESC II BED HERE -C ON4TYPE OR PRINT IN BLACK VVEL'L OWNER C. M. Miyoahi COLORADO DIVISION OF WATER RESOURCES , RECEIVED 101 Columbine Bldg., 1845 Sherman St... Denver, Colorado 80203 3 0 '73 LL COMPLETION AND PUMP INSTALLATION REPORT PERMIT NUMBER 812705- RF I wr�tx� A68a11 wa auk MW 1/ of the NW.. '4 of Sec. 1 ADDRESS Route 4 Box 3L3, Greeley, CO • T. N. R. 65 W, 6th P.M. 80631 April 2 , 1913 HOLE DIAMETER DATE COMPLETED WELL LOG From To Type and Color of Material Water Loc. 0 4 26 32 55 57 63 65 4 26 32 55 57 63 65 67 Use a Soil Gravel Sand gravel Gravel Clay Gravel Clay Shale TOTAL DEPTH 67 ft dditional pages necessary to complete log. a x x 8 in. from -... - -0 , to 67 ft, in- from to ft. in. from to ft, CASING RECORD: Plain Casing Size 5" & kind PVC from 0 to ft. Size & kind __ - from ,� to — � ft. Size & kind from to ft. Perforated Casing Size _.— & kind _PVC from _ to ,7.. ft. Size & kind from to ft. Size & kind from to ft. GROUTING RECORD Material Cenaent Intervals 0 to 10 ft. Placement Method . Pbur GRAVEL PACK: Size Pea Gravel Interval 10 to 67 ft. TEST DATA Date Tested ... --. AP l , 19 Static Water Level Prior to Test 24 ft. Type of Test Pump Blued ' -- Length of Test . 2 hours •' . • .- Sustained Yield (Metered? ` GPM • Final Pumping Water Level +•v5 it .. PUMP INSTALLATION REPORT jump Make Type 'owered by HP j ump Serial No. Vlotor Serial No. )ate Installed j ump Intake Depth 'YELL TEST DATA WITH PERMANENT PUMP )ate Tested static Water Level Prior to Test _ength of Test Hours 7ustained yield (Metered) GPM Jumping Water Level �.._�__ .rm_,r. _�.... _ Remarks OTAL DEPTH CONE OF DEPRESSION CONTRACTORS STATEMENT The undersigned, being duly sworn upon oath, deposes and says that he is the contractor of the well or pump installation described hereon; that he has read the statement made hereon; knows the content thereof, and that the same is true of his own knowledge. Signature R & R WELL & PUMP INC. by ,Fr• License No. 51 3 State. of Colvrad"of County of W , T_,__ SS Subscribed and sworn to before me this day of My Commission expires: June 13 Notary Public ,;,..07d-1.2-, , 19. 197 FORM TO BE MADE OUT IN QUADRUPLICATE; WHITE FORM must be en original copy on both sides and signed. WHITE AND GREEN copies must be filed with the State Engineer. PINK COPY is for the Owner and YELLOW COPY is for the Driller. 3 WRJ-5-72 iC COLORADO DIVISION OF WATER RESOURCES 101 Columbine Bldg., 1845 Sherman St., Denver, Colorado 80203 RECEIVED a • 1 ' Application must be complete where applicable. Ty6e or `print in BLACK INK. No overstrikes or erasures unless initialed. PERMIT APPLICATION FORM { ) A PERMIT TO USE GROUND WATER ( ) A PERMIT TO CONSTRUCT A WELL FOR: ( ) A PERMIT TO INSTALL A PUMP ( X) REPLACEMENT FOR NO. R12705 ( ) OTHER MAR /3 WATER RAl o jams STATE MINIM! coca. Partial Replacement (1) APPLICANT - mailing address NAME C. M. Mivoshi STREET _11._4_1ilca 313 CITY (State) Greeley Colorado 80631 TELEPHONE NO. 352-5619 (2ip) (2) LOCATION OF PROPOSED WELL County weld NW V of the NW '/4, Section 15 Twp 5 D1 , Rng. 65 W , 6th P.M. (3) WATER USE AND WELL DATA Proposed maximum pumping rate (gpm) 20 Average annual amount of ground water 3 to be appropriated (acre-feet): Number of acres to be irrigated; Proposed total depth (feet): 70 Aquifer ground water is to be obtained from: Alluvium Owner's well designation GROUND WATER TO BE USED FOR: ( ) HOUSEHOLD USE ONLY ( ) DOMESTIC (1) ( ) LIVESTOCK (2) (X) COMMERCIAL (4) - no irrigation (0) ( ) INDUSTRIAL (5) ( JC) IRRIGATION (6) ( ) MUNICIPAL (B) ( ) OTHER (9) (4) PR.ILLER Name R & R Well and Pump Inc. Street 145 16th Street City Greeley Telephone No. 353-3118 Colorado (State) Lic. No. FOR OFFICE USE ONLY: DO NOT WRITE IN THIS COLUMN Receipt No IV 980 Basin Dist. CONDITI9NOF APPROVAL This well shall be used in such a way as to cause no material injury to existing water rights. The 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 right from seeking relief in a civil court action. APPROVED AS A REPLACEMENT FOR A PORTION OF WELL REGISTRATION NO. 12705. UPON COMPLETION OF THIS NEW WELL, AN AMENDED STATEMENT OF BENEFICIAL USE MUST BE FILED FOR WELL REGISTRATION NO. 12705., A DECREE FOR THIS CHANGE IN WATER RIGHT MUST BE OBTAINED FROM THE DIVISION WATER COURT. AV M. elhad .c /97.5 EXPIRECil APPLICATION APPROVED PERMIT NUMBER DATE ISSUED EXPIRATION DATE R 12,7 far -ref MAR 2 91973 MAR 29 1974 I.D. COUNTY w (5) THE LOCATION OF THE PROPOSED WELL and the area on which the water will be used must be indicated on the diagram below. Use the CENTER SECTION (1 section, 640 acres) for the well location. NORTH+ W x J a 0 I- I- to - 1 MILE, 52$0 FEET -- + 4- + + + NORTH SECTION LINE T I I I I - - + I I - - - + .-- r I SOUTH SECTION LINE m LP, O x r_ z m The scale of the diagram is 2 inches = 1 mile Each small square represents 40 acres. (6) THE WELL MUST BE LOCATED BELOW by distances from section lines, A 1000 ft. from North . A sec. line 250 ft. from LOT —BLOCK (north or south) I to EMZ 1441, C ec. (east or west) FILING # SUBDIVISION (7) TRACT ON WHICH WELL WILL BE LOCATED No. of acres . Will this be the only well on this tract? (8) PROPOSED CASING PROGRAM Plain Casing in. from _in. from Perforated casing ft. to - ft. ft. to ... .. . ft. in. from ft, to ft, in, from ft. to ft. WATER EQUIVALENTS TABLE (Rounded Figures) An acre-foot covers 1 acre of land 1 foot deep 1 cubic foot per second (cfs) ... 449 gallons per minu [gpm) A family of 5 will require approximately 1 acre-foot of water per year. acre-foot . - . 43,560 cubic feet . - . 325,900 gallons. • 1,000 gpm pumped continuously for one day produces 4.42 acre-feet. (9) FOR REPLACEMENT WELLS give distance and direction from old well and plans for plugging it; (10) LAND_ON WHICH GROUND WATER WILL BE ��SED: Owners) Legal description: (11) PETAILEQ QE HIPTION of the use of ground water: - Greenhouse -- No. of acres! Less than 1/2 acre (12) OTHER WATER RIGHTS used on this land, including wells. Type or right Used for (purpose) Description of land on which used (13) THE APPLICANT(S) STATE(S) THAT THE INFORMATION SET FORTH HEREON IS TRUE TO THE BEST OF HIS KNOWLEDGE. 7,7/ SIGNATURE OF AFPLICA Use additional sheets of paper if more space is required. f e. 2.0r'-' g2 '� a 37 -?0-O76 7 ,iJOHN A? LOVE G vverrJr f DIVISION OF WATER RESOURCES DEPARTMENT OF NATURAL RESOURCES W. G. WILKINSON P.E. IRRIGATION DIVISION ENGINEER ROOM 208 8th AND 8th OFFICE BLDG, GREELEY, COLORADO 80631 OFFICE: 351-8712 HOME: 484-3917 March 14, 1973 Mr. Harlan Erker Division of water Resources 101 Columbine Building 1845 Sherman Street Denver, Colorado 80203 Dear Harlan: REci NED ikiAR 15'13 >8vige 40740. C. J. KUIP8 $te. Fnpfneer Dugan discussed this matter with you and Kupe. He says that it was - decided to call this a partial replacement for well located NW NW 15-5N-65, Registration No, 12705. Mrs. Miyoshi says that the original well which is registered for 1200 gpm has an application in court for 800 gpm. Dugan suggests that this well be approved for 20 gpm and the registration be re- duced accordingly. This well will be used in a greenhouse on the same acreage supplied by the original well. The use will be for less than two hours per day over approximately four months annually. The total consump- tive use will be somewhat less than previous uses. Sincerely yours, 0 1 s R. Clark A sistant Division Engineer dw Enclosures Os-. 'r .r J 444/4"( ;)/. (,;2 70 s e r t£ f4kc_rte . T _ ka i utvrJrv1Y ►I Moo= rraai ntracntfr V Irr r ItioAcsotatorw r.iz.-..n1f Meese fora t ie tern, In INK RP131. niceiPt nOK 1Mi 00 � / 77 I 77 PilivPosEOFmavanotv; ci+lE me. OU t" fi/ J1r4N1 /4.44, 4 4/ .F /1_, Vr 1� • pel f? congealed ifnot applicant ,qr, f. 1 • rc )4.' .� ADORES& i72_ f o CA. Av. W.C.0WN &phase# ;7 1i et fl - Li raze/ r/ III- 1 RECEIVED -ic 1- ‘ - /11'- �r o ' - /f '18'93 I BUSTING WEIL OOA77O11 STATE N 1II, Sec, 1 , , ` 'CG ' P.M. 5. USE T ) hort °/1s nam t aacine; c wi y 44 # (1I mpl., diaL S dlr. to ° AD.- � . I okofe type of existing . „ j rr , .DOG, WNW WELL, GAUERYWEU,GRAVEL PIT, per- 12 w5-ofFi _ - - smother wets em locatedonUdep ef?(Yo hammy ((J'°, p.r.!/tS,o...F3r•24' r1 -F r EST. DATE WELL co srnucrw ` / / 45 DATE USE / '3 ESE PIRIVINO RAM gpm TOTAL # OFAr,•REg NMI Tr /PARCEL / ACRES address of properly O ~dim appphce t ) # acms Irrigated (norm mpticrop hr,) ... / MAC of AUG. A 0,1 ire." u KJ -6/et/,Th; USE OF WELL: household use In plicate how rnsrly .w slide tan* deraffing(e) wouome of poultry and/or dontaello BAUWS MIMI& would Include a I w cows, homes, eta wafering of &mock on a faugstmgag— ewer Iiow army bead? e; is thisafeed lO? ;how many heed? (it is b specter estimated ilia& law Wga den In) In — -- - square fbetlacre Worm and/or garden fhe protection _ carnmarelot — drinking & son, onlj? data% hi ccemmaot section) other (wrh9 dulls In eaonrserar sactkwi) / fro IF WERE THE USES CHECKED ABOVE INITIATED PRIOR TO MAY 8, 1972? NOTE:Anrr IN r �c r rl w�li acc� slur mar �. �. eta icaGettuaantiaLmatcasizatagsituauftsllarloaiarldior erma„arort of the crnrrl9rmlar nrnn d u In Ore toneralideimam ofthla form (if completing Inspection for NON-EXSIPT USES, use danmarJte sootlon below (include case #, # ecr Inr if applicable; elan report taken bydated! -- j ; ceded in by: additional comments and/or irdorn err ; _ _ . /2J C-0-17 MINN to be completed In INK .4 APPurm, ADDRESS!' FA] DATE CALLED ii Tai BY 6 ,NAME OF CALLER Appfrtl Won .1.....-..I By niKtolPt # Apprami # 11E greneej APPROVAL CIVlwN ¢m., empinit X54 }:ere credziey, (7< 0'6 / USE OF WELL: r ► a ,� C rQ�s F. CONTRACTOR e- e 4" ADDFIESS: /3c2 61" C-77 uca;, e 5.7 - : mono: 'a 3 -3'- /A7 (co .AFPLRECEIPT A&DATE PI Mir + 7 A 7d s Lftig DARE # 79 c,q 0-O PROPOSED LOCATION OF (nab WELL AUG FLAN NAME h. ( •4 'w P r1/Ztl 1/4 .. 114. sec. ! .T41. .. 5-4/ Rfq. 6 G ' /. / ey P.M, DIST 9 00; . d sou. 0' k'C , f o+ £ C a Y distance & direction from old moll to new will site — D r 5 DEEPEN (circle if deepen) subdivision Ho: IOW IF ve. 2 / i[(s) / -, bit fig. Buddy. .ionspsi # e. /AIXIRESS OF WELL, ■ all. rd thin vomit add; - REASON Fon EMEROENM OUT OF WATER OCCUPIED FED? no) STOOK ON PASTURECT P 1RRIC ATlON Oligalg* OTHER-- GAsiNe INFO: DEPTH OF OLD WEIL? A- / : PROPOSED DEPTH? .. f : AQUIFER? Gr cAnNen plain plus 1 l /6 " pods. 6 /6 4' DATE TO START? , f /S 1 #'-7 FIELD INSP. REQ,? YE ( NO ) veer for field inspsctlon report Information; celled !n? — date 1 /17t,7 VALUATING STAFF CO liuoENrs; CONOmONls OF APPROVAL; EVALUATED 6Y: # DATE: • APPROVED BV' ' DATE:________, __ _ onaroY pmnALA FORM Nb. 7/89 ' STATE OF COLORADO OFFICE OF THE STATE ENGINEER 818 Centennial Bldg., 1313 Sherman SL, Denver, Colorado 50203 (303) 88&3581 For Office Use only }' RECEIVED IEW 22 1B mATEARESEURCIES STMUIRK0NEER MUT TIDE OR PRINT IN BLACK INK WELL ABANDONMENT REPORT ABANDONED WELL NUMBER IF REGISTERED 1270 5 R 1. INDAIIpuAL/GoMPANY RESPau,pE FOR PLUGGING NAMES) Mailing City, Phone _ Hamako !Kiyoshi Address 2120 Cherry Ave. St. Zip Greeley, Co. 80632 (303 ) 352-5619 2. 6OTUAL WELL LOCATION: COUNTY Weld PROPERTY NW ADDRESS (Address) 1/4 NW 1/4, Sec. 15 Twp. (CRY) (State) PP} 65 ❑ E. EIW. 6 P.M. 5 © N. ❑ S., Range Distances from Section Lin Ft. 80 Ft, from ❑ E. from +l N. ❑ S. Line, or MI W. Line. _212,9 3. I (we), report that an existing well was plugged and abandoned for the following well was plugged and abandoned as required under the conditions approval of Well Permit No. 12705 H H . reason(s): of gi The ❑ The well was/ not in use and was abandoned. (please explain) ❑ Other 4. The well and was plugged and abandoned according to the Water Well Construction Pump Installation Rules on 7-30-93 _ - , 19 5. The well was plugged with the following materials placed at the indicated intervals: -- AMOUNT AND TYPE OF MATERIAL METHOD OF PLACEMENT INTERVAL Sand. 8, Gravel Poured from 35 feet r to 110 feet to 5 feet Cement Poured from 10 feet from 5 feet Top soil Pushed In to ° feet to feet from feet from feet INTERVALS OF CASING REMOVED/RIPPED IN FEET to feet from feet to feet 6, I (we) have read the statements made herein and know the contents thereof, and that they are true to my (our) knowledge. [Pursuant to Section 24+4-104 (13)(a) C.R.S., the making of false statements herein constitutes perjury in the second degree and is punishable as a class 1 misdemeanor.] Name/Titie (Please type or print) OWNER Hamako Miyoshi Signature ,._±...ZZd„,,,,„fe ,, , Date 9-9-93 -INFORMATION- It is the responsibility of the well owner to have the well properly plugged and abandoned. The well construction contractor is responsible for notifying the well owner of the plugging and abandonment requirement, This form may be reproduced by photocopy or word processing means. r -f ' ?RR Tr Forte F (Rev. 7-5715M STATE OF COLORADO 4- DIVISION OF WATER RESOURCES • 'e 6 19BP OFFICE OF THE STATE ENGINEER, GROUND WATER SECT#('; f REGISTRATION NO. 1,'7().6 WELL STATE ENGINEER Registrant C. M. Miyoshi and Hamsko Miyoshi Date 4/25/6019_ P.O. Address Rt 4, Box 313, Greeley, WELL DATA Depth 70 'eft. Diameter 24 in. Casing - ft. Plain; - ft. Perfor. Static Water Level 25 ' ft. from top Yield 1200. (gpm)(s) from 45 ft. on/at Used for iiri aeon NWl Sec 15, Township 5 N, Range 65 (legal description of land or site) Water conveyed by open size PUMP DATA Type Peerless Size . p inch rrl o t Driven by a lec trio aL 10 HP RPM Well was first used sprinq of , 19 38 cfs for irrigation using 1200 gpm WELL TO BE LOCATED AS ACCUR- ATELY AS POSSIBLE WITHIN A Well enlarged - - 19 to SMALL SQUARE WHICH REPRESENTS deepened 40 ACRES; OR IF IN A TOWN OR - - (gpm)(cfs)(ft) SUBDIVISION FILL IN THE FOLLOW- ING: , Colo. WELL LOCATION County Weld 6 2 SW tr, NW 4, Section 15 Twp. 5 N . Rge. 65 W 6th PM N _....,._..„..._. I r I I I I � I I _____ E LOG SHOULD BE GIVEN ON REVERSE SIDE IF AVAILABLE S Town or Subdivision Street address or Lot and Block The above well (has) (has not) been registered in the Office of the State Engineer prior to May 1, 1957. If Registered give Filing No. If NOT Registered prior to May 1, 1957, a $5.00 filing, fee accompanies this form. The above statements are true and correct to the best of my knowledge and belief. Subscribed and Sworn before me 25th day of Aptil , 19 6Q this My commis Ion,. expires January 7, 1962 Regi (SEAL) 1-' • otar Pudic FOR STATE ENGINEER'S USE J Located in_ /— district, ( Jam1 . _ _ ..County for -, Registration No. ..17 ,0 in / — , Scanning Cover Sheet for Septic Permits Permit # Permit Type: G19760269 Health / EHS History / EHS Conversion History Situs Street Address 2120 CHERRY AV Situs City, State, Zip Sec/Town/Range: 15 -05N -65W Parcel # (12 digits) 096115200015-R3391086 Owner Full Name: Owner Address: Contact Name: Contact Address: MIYOSHI CHARLES 2120 CHERRY AVE. GREELEY,CO 80631 Application Status: Finaled Application Date: 03/11/1996 Owner Phone #: 303 3525619 Contact Phone# Information above has been Verified in Accela by employee noted below X February 10, 2009 Processed by: Date Report ID: EHS00024v003 Page 1 of 1 Print Date -Time: 2/10/2009 2:51:10PM p. rk WELD COUNTY HEALTH DEPARTMENT 1516 Hospital Road Greeley, Colorado Ph. 353-0540 lou.a)Lecl PERMIT NO. .2C? 9 Application for permit to Install, Construct, an Individual Sewage Disposal System. Owner (_.A,( .Ai L i YL {.,Vo /_/LL- Address _e),/,96,) 0/ i ( J I.(xehone 26 .) - 3, P=1 Direction. to site: Hwy Rd. N mi., E. mi., S_mi., mi. r/1 CI r) ( t)( � � r; ' 4 .311 Legal Description: Ptn Nw4ec. 15, T N, R AtiSubdiv. Lot Blk General Information No. Bedrooms J No. Persons No. Baths / Basement Plumbing Size of Lot 3.5 t, .c') -6Z rI, / H2O supply (if well give depth) ;t{J.-�{./_ (t f New Home Mobile Home Modular Add'n Type of sewage ,disposol requested: Septic tank Privy Other Trts cer't.I'E Ic:s -Ihct-1 �I.%e 54t;ry �/�j l`> NOT (.U, -kin. 4O0' of i�ubl.c SC'u r ' 'L�/ /,�.Ji Septic Tank Other /000 Dept. Use Only Perc. Rate (Avg. of 3) / 17/0 /rx2.11, . Soil Type Sa louac H2O Table Depth > e/ Lot Grade 4 30 7o Requires Engineer Design Yes_K_No If yes — reason I�Amrnents: Installation Instructions: (Minimum Requirements) Gals. Special Instructions Absorption Trenches Y %.� Sq. Ft. or Seepage bed t ys Sq. Ft. .This system will be constructed and installed in accordance with the above specifications and regulations re- garding individual sewage disposal systems 'in 'Weld County, Colorado This permit. shall expire at the same time as the building'permit, or, if no building permit is issued, the permit shall expire 120 days after its issuance, if construction has not been commenced. ' Date: (-fSL.f12 �� , , /�%1 /a/ Owner: ��'` �� 2!"`i el5 Applicant: The plans and specifications as shown are approved pending payment of permit fee. Date: /D//yr__76 Sanitarian ,Zl"ct 70: The above system inspected and found to comply with plan and description. Contractor: ��' APL `• -t - l/ Systems Engineer. Review: 'r Permit Fee: $/ -� Received by: •'1„1f .i :rf_.(' Date• Sanitarian: (Dote) (Signature) Date: „Ali! 7 �` n /9 7� it DP' ti tp \_/ WUDe COLORADO • LOAN APPROVAL. CLOSING DATE: 03/14/96 FAX FEE ($2.00): N/A NEW LOAN `---c6.0D_(_o� DEPARTMENT OF HEALTH 1517 16 AVENUE COURT GREELEY, COLORADO 80631 ADMINISTRATION (970) 353-0586 HEALTH PROTECTION (970) 353-0635 COMMUNITY HEALTH (970) 353-0639 FAX (970) 356-4966 REQUEST NO: 031-96/0247 DATE RECEIVED: 03/06/96 FEE $90.00: 03/06/96 TO WHOM IT MAY CONCERN: Review and inspection report regarding water and the sewage disposal system for an existing dwelling: SEND TO: Pro Realty Jim Ferguson 3545 Nest 12th Street Stuite 101 Greeley, Colorado 80631 REALTOR NO.: 353-1117 OWNER NO.: (303) 425-7318(H) OWNER NO.: (W) INFORMATION: Address: 2120 Cherry Avenue. Greeley. Colorado Age of Septic: 1976 Legal: PT: PT: SEC: 15 TWN: 05 N RNG: 65 W Subdivision: N/A LOT: BLK: FLG: Property Owner: Miyashi Trust Original Owner: Miyashi, Charles Tank Pumped on: 03/05/96 By: Slim's Sanitation ' Licensed: es PERMIT ON RECORD: Name: Miyashi, Charles Permit No.:G-760269 S.O.E.: No Bathrooms: 1 Bedrooms: 4 Total Acres: 5 Date of Final Inspection:11/05/76 Water Supply: Greeley Well Permit No.: N/A Tank Capacity: 1000 gallons Field Size: 891 Square feet INSPECTION FINDINGS: Date of Inspection: 03/07/96 Soil Conditions:- Dry xxx Saturated Snow-covered Residence: Occupied xxx Vacant Sewage Disposal System: Satisfactory xxx Other Bacteriological Water Test: Acceptable xxx Other COMMENTS: None Applicable. DATE: 03/08/96 SIGNATURE: Environmental Protection Specialist Neither the County of Weld, nor any of its agents or employees undertake or assume any liability to the owner of the above property, to any purchaser of the above property or to any lending agency making a loan on the above property in connection with either its examination of the property or in the report. . This inspection was conducted solely for the purpose of detecting health hazards observable at the time of inspection, and does not constitute a warranty that the system is without flaw or that it will continue to function in the future. Inspections requested during periods of snow cover and high soil saturation may be of questionable value to potential buyers due to adverse conditions. Water sample reports reflect the bacteriological quality of the water supply at the time the sample was. taken. Evaluations based on Statements of Existing (S.O.E.) relies on information the property owner provides, under oath, indicating current status of the system and representing to the best of his/her knowledge the system is not failing to function properly. Residence:. Occupied _ Sewage Disposal System: Satisfactory Bacteriological Water Test: Acceptable • c -I 1 R LOAN APPROVAL Weld County Health Department NEED: TO WHOM IT MAY CONCERN: disposal system for an existing dwelling: SEND TO: Pro Q//ki �NCYC f (m) �S�/� Cr) PICK-UP: FAR TO: SPECIALIST INSTRUCTIONS: (1) 4j ( p0_ LL, ar, i/j cu ,23o r- ri rt v d! (Jo QUao,c- CLOSING DATE: 3- //'17/4- 6 REQUEST NO: 3/41 y2 FAX •I PICK-UP DATE RECEIVED: —9e; FAX FEE .00): RECEIVED BY: 0 NE OAN RE -FINANCE FEE /$. 0� / $105.00: 7j -in -y6 Review and inspection report regarding water and the sewage REALTOR NO .: -,5.5,--/// 7 OWNER N00:65 -25-22517'(H) - OWNER NO.: (W) FAX NO.: INFORMATION: Address: Legal: PT: ::2/:2Q C./ y(L 1:0(_g__, :0(_Greel,e.)c Age of Septic: 7(c PT: USEC: ).S TWN: Q`5 N RNG: 6s W Subdivision LOT: BLK: . FLG: Property Owner: flf u '/ i ru5'L Original owneer:(7,Inf (p,c ash Tank Pumped on: 315-94/., By: (�/(I%h, c ,q001.-,)/,',\_____ Liicensed:CD N PERMIT ON RECORD: Name: ih I .t 0 If 0/K.82-<1 Permit No .:76626 7 S .0.E.: Y N Bathrooms: Bedrooms:,L,/J Total Acreage: s Date of Final Inspection: Water Supply: Greg/� J% Well Permit No.: Tank Capacity:I(r% llons Field Size: square feet INSPECTION FINDINGS: Date of Inspection: 3-- 9. - Soil Conditions ;Dry, „ Saturated Vacant COMMENTS: Other Other DATE: $1114(0 SIGNATURE: Environmental Protection Specialist Neither the County of Weld, nor any of its agents or employees undertake or assume any liability to the owner of the above property, to any purchaser of the above property or to any lending agency making a loan on the above property in connection with either its examination of the property or in the report. This inspection was conducted solely for the purpose of detecting health hazards observable at the time of inspection, and does not constitute a warranty that the system is without flaw or that it will continue to function in the future. Inspections requested during periods of snow cover and high soil saturation may be of questionable value to potential buyers due to adverse conditions. Water sample reports reflect the bacteriological quality of the water supply at the time the sample was taken. Evaluations based on Statements of Existing (S.O.E.) relies on information the property owner. provides, under oath, indicating current status of the system and representing to the best of his/her knowledge the system is not failing to function properly. Scanning Cover Sheet for Septic Permits Permit # G19800170 Permit Type: Health / EHS History / EHS Conversion History Situs Street Address Situs City, State, Zip 2120 CHERRY AV Sec/Town/Range: 15 -05N -65W Parcel # (12 digits) 096115200015-M0006491 Owner Full Name: MIYOSHI HAMEKO Owner Address: 2120 CHERRY AVE. GREELEY,CO 80631 Contact Name: Contact Address: Application Status: Finaled Application Date: 03/11/1996 Owner Phone #: 303 3525619 Contact Phone# Information above has been Verified in Accela by employee noted below X Processed by: January 20, 2009 Date Report ID: EHS00024v003 Page 1 of 1 Print Date -Time: 1/20/2009 8:47:04AM WELD COUNTY HEALTH DEPARTMENT 1516 Hospital Road ,Greeley, Colorado PH. 353-054,0 SO D Permit No. / • �- 1 Application for perm -install_, construct,•an Individual Sewage Disposal System. Owner 1 iQ rn .ko Di ( y S k t Address ( �\--) h"-5 4-1 4`5'a; • Phone _ Directions to site: Rd. N mi, E mi, S mi, W mi Legal Description: Ptn.(r(W]jN U Sec. (5- ,T _S N, R(,S W, Sub. ,•.1rk Lot Blk _ v\ t•-• No. Bedrooms _ No. Baths Size of Lot H2O supply (If well give depth) Lii<156„._(„:41 3. — ('.41 New Home Mobile Home ✓ Modular Add'n _ Type of sewage disposal requested: Septic tank '/ Privy Ofher General Information - No. Persons 4 ,a- 2w,,4?- Basement Plumbing. crcr S rDept. Use Only 1 Perc rate (avg. of 3) 67./4,44 Soil Type spy H2O Table Depth _ Lot Grade Engineer Design Yes No If YES -reason: Comments: This is to certify that the system is NOT within 400 ft. of a public sewer Installation instructions: (Minimum Requirements) Septic Tank 767) Gals. Absorption Trenches _ Other or Special Instructions Seepage Bed _ f_ElG /41erv-' •E4,E 5��cf1 .» 76Af�GrJ Di2� This system will be constructed and installed in -.-accordance with the above specifications and regulations regarding individual sewage disposal systems in Weld County, Colorado.. This permit shall expire at the same time as the building permit, or, if no building permit is issued, the permit shall expire 120 days after its issuance if construction has not been commenced. Date: / --- Rd Owner: Sq. Ft. Sq. Ft. Applicant : •� r" The plans and specifications as shown are approved pending payment of permit fee. Date: The above system inspected and found to Systems Contractor: Engineer,Review: Permit Fee: $ (Date) • comply with plan and gettion. iblet Sanitarian:. Date: Sanitarian`, 6;2(it•-•-Z4/17t/krvi Received by: Date: (Signature) r': cam: ' � • 19-79-122 •J 1T' • 36 0 1 COLORADO From Planning Department Date Environmental Protection Services Subject. I . S . D . S .: MIYOSHI, HAMAKO January -23, 1991 OWNER: MIYOSHI, HAMAKO MAILING ADDRESS: SITE ADDRESS: 2120 Cherry Avenue 2102 Cherry Avenue Greeley City Greeley City Phone: 352-5619 CO . 80631 State Zip CO 80631 State Zip LEGAL DESCRIPTION: PT NW4 PT NW4 SEC 15 TWN 05 RNG 65 SUBDIVISION: _ LOT BLK FLG _ The septic system identified above XXX is, is not of sufficient size to accomodate the proposed alteration(s) indicated bedow to the structure(s) served by this system. CURRENT FLOW: TAKEOFF HOUSE & GREENHOUSE Persons • 4 Bedrooms 0 Bathrooms 1 ADDITIONS: -2 PROPOSED TOTAL:. MOVE MOBILE HOME.ON ON 2 2 - 2 1 Permit on Record: NAME MIYOSHI, HAMAKO 2 NO. G-800170 Recommend avoiding any machinery traffic over absorption bed. Greeley r City of Greeley Director of Finance P.O. Box 1928 Greeley, CO 80632-1928 Account Number 062-800941-01 Service 2120 CHERRY AVE Location Meter ID 10059098 03/01 1024 02/01 1022 5 4. 3 2 Date Curr Read Date Prey Read (Usage in thousand gallons) Used Statement of Account for Utility Service(s) THANK YOU FOR YOUR PROMPT PAYMENT. Inte 411 Usage 2 Payments Bal Fwd RESIDENTIAL WATER D J F M RESIDENTIAL WATER Residential Water Base Charge Used Rate Amount 2 11.620 $23.24 $17.36 $28.98- $0.00 $40.60 CURRENT CHARGES $40.60 [TOTAL DUE ON 03/21/22 $40.60 Hello