HomeMy WebLinkAbout20151080.tiff COLORADO DIVISION OF WATER RESOURCES Office Use Only Form GWS-45(07/2013)
DEPARTMENT OF NATURAL RESOURCES
1313 SHERMAN ST, RM 821, DENVER, CO 80203
Main: (303)866-3581 Fax: (303)866-2223 dwrpermitsonlinenstate.co.us
GENERAL PURPOSE
Water Well Permit Application
Review instructions on reverse side prior to completing form.
The form must be computer generated,typed or in black or blue ink.
1. Applicant Information 6. Use Of Well (check applicable boxes)
Name of applicant
Attach a detailed description of uses applied for.
NGL Water Solutions DJ, LLC
❑ Industrial ❑ Dewatering System
Mailing address Municipal❑ P ❑ Geothermal(production or reinjection
3773 Cherry Creek North Drive
Irrigation
City Stale Zip code ❑
Denver CO 80209
Commercial ❑ Other(describe):
Telephone#(area code&number) E-mail(online filing required) 7. Well Data (proposed)
303 868 1286 info@highsierraenergy.com Maximumpumpingrate Annualamounttobewithdrawn
2. Type Of Application (check applicable boxes) 15 gpm .33 acre-feet
Construct new well ❑ Use existing well Total depth Aquifer
❑ Replace existing well ❑ Change or increase use 100 feet ALL UNNAMED
❑ Change source(aquifer) ❑ Reapplication (expired permit) 8. Land On Which Ground Water Will Be Used
❑ COGCC Well ❑ Other:
Legal Description of Land(may be provided as an attachment):
3. Refer To (if applicable)
Well permit# water Court case# SE of NE 1/4 of S27-5N-63W
Designated Basin Determination# Well name or# Land used for construction & operation
4. Location Of Proposed Well of a salt water disposal facility
County (If used for crop irrigation,attach a scaled map that shows irrigated area.)
Weld SE 1/4 of the NE 1/4 A. #Acres B. Owner
Section Township Nor S Range E or W Principal Meridian 35 NGL Water Solutions DJ, LLC
27 5 ® 63 ® IM 6th c. List any other wells or water rights used on this land:
Distance of well from section lines(section lines are typically not property lines) NA
Ft.fromON OS Ft.fromf E�W
For replacement wells only—distance and direction from old well to new well 9. Proposed Well Driller License #(optional): 1461
feet direction 10. Sign or Entered Name Of Applicant(s)Or Authorized Agent
Well location address(Include city,State,Zip) ❑cheek if well address is same as in Item 1 The making of false statements herein constitutes perjury in the second
degree,which is punishable as a class 1 misdemeanor pursuant to C.R.S.
NA 24-4-104(13)(a). I have read the statements herein, know the contents
thereof and state that they are true to my knowledge.
Optional: GPS well location information in UTM format You must check GPS unit for Sign or enter name(s)of person(s)submitting application Date(mm/ddlyyyy)
required settings as follows:
Format must be UTM
If signing print name and title
Ell Zone 12 DU Zone 13 Easting 549693
Units must be Meters
Datum must be NAD83 Northing 4468958 Office Use Only
Unit must be set to true north
YES USGS map name DWR map no. Surface elev.
Was GPS unit checked for above?
❑ Remember to set Datum to NAD83
5. Parcel On Which Well Will Be Located
(PLEASE ATTACH A CURRENT DEED FOR THE SUBJECT PARCEL) Receipt area only
A. Legal Description(may be provided as an attachment):
SE OF NE 1/4 S27-5N63W
B. #of acres in parcel C. Owner AOUAMAP
35 NGL Water Solutions DJ, LLC WE
WR
D. Will this be the only well on this parcel? E YES®NO(if no list other wells) CWCB
TOPO
E. State Parcel lD#(optional): MYLAR
SB5 DIV _ WD___ BA _ MD ___
Weld County Environmental Health Services Department
1555 N. 17th Avenue
t� Greeley,CO 80631
Phone: (970)304-6415
Fax: (970)304-6411
Web:www.co.weldhealth.org N.�� _
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Septic Permit Application
Application Number: SP-1500005
App Type: Health\Commercial\New OWTS\Septic
ASHLEY GARCIA
2861 W 120 AVE#250
WESTMINSTER, CO 80234
Owner Name: 70 RANCH LLC
Parcel#: 096527100022-O3231205
Legal Desc: LEASEHOLD INTEREST NENW 27 5 63 PERKINS 21-27 JS
Site Address:
App Specific Info:
Location Description TBD
Number of Persons 10
Parcel Acres 35
Public Water Supply No
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 true and correct to the best of his/her knowledge and are
designed to be relied on by the WCDPHE for evaluation for purposes of issuing the permit applied for herein.Applicant further understands
that falsification or misrepresentation may result in the denial of the application or revocation of any permit granted,and in legal action or
perjury as provided b law.
X 1
Own /• man / Da e
Report ID: EHS00056v003 Page 1 of 1
Print Date Time: 1/12/2015 2:56:33PM
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SEPTIC PERMIT INFORMATION FORM
Wine
COLORADO To obtain an I.S.D.S. permit,one must file an"application for Individual Sewage Disposal System"
at the Weld County Environmental Health Services office and pay the application fee. A "repair"fee
shall be charged for the expansion, replacement, or repair of an existing system. The following
information must be provided on the septic information form.
COMMERCIAL PERMIT J RESIDENTIAL PERMIT
NEW or REPAIR $850.00 NEW or REPAIR $750.00
VAULT PERMIT MINOR REPAIR PERMIT
NEW or REPAIR $250.00 $100.00
PARCEL NO.: 0965-27-1-00-022 (12 DIGIT NUMBER)
LEGAL DESCRIPTION: SECTION 27 TOWNSHIP 5N RANGE 63W ACRES 35
SUBDIVISION NA LOT NA BLOCK NA FILING NA
THIS INFORMATION CAN BE OBTAINED FROM THE ASSESSOR'S OFFICE AT (970) 353-3845 EXT 3650
SITE ADDRESS 104 24'53"W 40 22'8.2""N
DIRECTIONS TO SITE Take CR 69 North to CR 388&turn Left, access is on North side after 1000'
PROPERTY OWNER: 70 Ranch, LLC
MAILING ADDRESS: 8301 E Prentice Ave#100 CITYGreenwood VillageST CO Zip 80111
HOME PHONE: (_ ) NA WORK PHONE(303) 815 l M 0 FAX( )_ NA
EMAIL ADDRESS: info@highsierraenergy.com
APPLICANT NAME: NGL Water Solutions DJ, LLC
MAILING ADDRESS: 3773 Cherry Creek North Drive#1000 CITY Denver ST CO ZIP 80209
HOME PHONE: ( ) NA WORK PHONE(303 ) 773 1005 FAX(303) 773 1167
EMAIL ADDRESS: jason@70ranch.com
DESCRIPTION OF BUILDING (EX: HOUSE,MOBILE HOME,MODULAR, SHOP, OFFICE) Lot
IF OBTAINING A REPAIR PERMIT, WHAT IS BEING REPAIRED? NA
NUMBER OF PERSONS H 0 IN FLOOD PLAIN AREA? YES/N6
NUMBER OF BEDROOMS NA PERCOLATION HOLES MUST BE MARKED FOR
INSPECTION OR A $50.00 FEE WILL BE CHARGED
BASEMENT PLUMBING YES/V
CENSUS TRACT
BATHROOMS: FULL 2 %_ %2
PUBLIC WATER SUPPLY YES/ NAME
PRIVATE WATER SUPPLY VS/NO w L/CISTERN PERMIT# Permit Application in progress
PLEASE DRAW A MAP TO YOUR PROPERTY.
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