The URL can be used to link to this page

Browse Search

Home My WebLink About20143325.tiff COLORADO DIVISION OF WATER RESOURCES Office Use Only Form GWS-44(7/2012) DEPARTMENT OF NATURAL RESOURCES 1313 SHERMAN ST.,Ste 821, DENVER, CO 80203 Main: (303)866-3581 Fax:(303)866-2223 Owrppermit gggline tale co.us, RESIDENTIAL Note:Also use thisform to apply for livestock watering Water Well Permit Application Review form instructions prior to completing form. Hand completed forms must be completed In black or blue ink or typed. 1. Applicant Information Ner, $) - 6.,Use Of Well (check applicable boxes) (pNU `1 l See instructions to determine use(s)for which you may qualify K O A. Ordinary household use In one single-family dwelling Mailing address (no outside use) ( C.‘1 \r"A^ CA. jr(B. Ordinary household use in 1 to 3 single-family dwellings: Cky Slate Zip code E(l2 Cu V?i(U Number of dwellings: Telephone(waroa code) E-mail O Home garderdlawn Irrigation, not to exceed one acre: 3p3 LU ' r)t)(9O (rtvb 4 ktrAuse0rcdt'tM+^ area irrigated In sq. ft.0 acre 2.Type Of Application (check applicable boxes) O Domestic animal watering—(non-commercial) .Construct new well O Change source(aquifer) O C. Livestock watering(on farm/ranch/range/pasture) ❑Replace existing well O Reapplication(expired permit) ❑Use existing well O Rooftop precip.collection 7.Well Data(proposed) ❑Change or increase use O Other: Maximum pumping rate Annual amount to he withdrawn gpm acre-feet 3. Refer To(if applicable) - Total depth Aquifer Weil Water Court case i feet Designated Basin Determination# vWll name ora - .. - - 8.Water Supplier Is this parcel within boundaries of a water service area7CI YES Ai NO 4, Location Of Proposed Well (Important!See Instructions) If yes, provide name of supplier: County 9.Type Of Sewage System @eld vawthe 1/4 lSeptic tank Section Township Nors Range EorW . Principal Meridian leach field 2-z ' -r-1N IP` a 61t.&) ❑ 11 O Central system: District name: - er Distance of non fomaedlon lines(section lines ere ryplmyy not Moped,/lines) ❑ Vault:Location sewage to be hauled to: Fi.torn EN r s Ft.fromCE OW O Other(explain) For replacement wells only-distance and direction from old well to new well feet Direction 10. Proposed Well Driller License#(optional): Well location address(Include City:Slate Zip). ❑check if well address is same es in Ilam i. 11. Sign or Enter Name of Applicant(s)or Authorized Agent 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. -- --- - ---- -- - 244-104(13)(a). I have read the statements herein,know the contents Optional: cps war location information to urM orris.. ors unit settings sro as follower thereof a state that they are true to my knowledge - Format must be UTM _._._ ..... S (inn or an mole) persos)submitting oppkotion Dare(mrNddryyyy) rr Zone 12 off.. Zone 13 Easting: ,�/ J Units suet be Meters Ai�1/ )-zpp 'I Li Datum must be NADAS Northing: Unit must be set to toe north If sipnHp tie end tins Was OPS unit checked for above?❑YES Rememberm cat DeWmto I�IADB3 / iCU—Nx-kir 5. Parcel On Which Well Will Be Located Office Use niy (You must attach a current deed for the subject parcel) uses map name DWR map no. Surface elm. A.You must check and complete one of the following: ❑ Subdivision: Name _ Receipt area only Lot Block Filing/Unit ❑ County exemption(attach copy of county approval&survey) Name/# Lot# )( Parcel less than 35 acres, not in a subdivision attach a deed with metes &bounds description recorded prior to June 1, 1972,and current deed ❑ Mining claim(attach copy of deed or survey)Name/#: ❑ Square 40 acre parcel as described In Item 4 ❑ Parcel of 35 or more acres(attach metes&bounds description or survey) AQUAMAP ❑ Other:(attach metes&bounds description or survey) WE B.#of acres in parcel C. Are you me owner of thls parcel? WR I YEa Cl Dwca D.will hts be the only well on It parcel? )(YESr I NO(if no-lid other wells) TOPO - - --- MYLAR E. Slate Pecoel ID#(optional): 555 DIV_ WD_ BA_ MD WATER SUPPLY INFORMATION SUMMARY Section 30.28-133,1d), C.R.S. requires that the applicant submit to the County,'Adequate evidence that a water supply that is sufficient in terms of quantity, quality and dependability will be available to ensure an adequate supply of water. 1. NAME OF DEVELOPMENT AS PROPOSED 2. LAND USE ACTION c itup 3. NAME OF EXISTING PARCEL AS RECORDED SUBDIVISION FILING BLOCK LOT 4.TOTAL ACREAGE j 3 5. NUMBER OF LOTS PROPOSED I PLAT MAP ENCLOSED 0 YES 6. PARCEL HISTORY • Please attach copies of deeds, plats or other evidence or documentation. A. Was parcel recorded with county prior to June 1. 1972? O YES ❑ NO B. Has the parcel ever been part of a division of land action since June 1, 1972? O YES 0 NO If yes, describe the previous action 7. LOCATION OF PARCEL - Include a map deliniating the project area and tie to a section corner. (� 114 OF 114 SECTION 2-1 TOWNSHIP Ti N ❑ N ❑ S RANGE P e'l t"}❑ E ❑ W PRINCIPAL MERIDIAN: Dti 6TH O h.M. 0 UTE 0 COSTILLA 8. PLAT• Location of all wells on property must be plotted and permit numbers provided. Surveyors plat O Yes isti No If not, scaled hand drawn sketch O Yes O No 9. ESTIMATED WATER REQUIREMENTS - Gallons par Oay or Acre Net par Year 10. WATER SUPPLY SOURCE O EXISTING O DEVELOPED O NEW WELLS - WELLS SPRING PROPOSED MFRS mass Oq HOUSEHOLD USE N of units GPO AF WELL PERMIT NUMBERS ❑nuurur ❑carte aasssnOE ❑ciao DAMN ❑uiwte ARAPAHOE MYR DAMN COMMERCIAL USE N of S.F. GPD AF a O MAW FOX cats MOD o Miff IRRIGATION I of acres GPO AF STOCK WATERING N of head _ GPO AF O Ma ICIPAL O ASSOCIATION WATER COURT DECREE CASE NO.'S OTHER GPO AF O COMPANY ❑ DISTRICT TOTAL GPO AF NAME LETTER OF COMMITMENT FOR SERVICE O YES ❑ NO 11. ENGINEER'S WATER SUPPLY REPORT 0 YES 0 NO IF YES, PLEASE FORWARD WITH THIS FORM. ITh6 may be reauhad Ware our review b amplified.) 12. TYPE OF SEWAGE DISPOSAL SYSTEM ftcSEPTIC TANKILEACH FIELD O CENTRAL SYSTEM • DISTRICT NAME ❑``LAGOON O VAULT LOCATION SEWAGE HAULED TO O ENGINEERED SYSTEM (Attach r wpy of enamoring design) O OTHER COLORADO DIVISION OF WATER RESOURCES GWS-44 RESINST(7/2012) DEPARTMENT OF NATURAL RESOURCES RESIDENTIAL WELL PERMIT APPLICATION INSTRUCTIONS Applications must be computer generated online, typewritten, or not need to provide distances from section lines or a GPS printed in BLACK or BLUE INK. ALL ITEMS in the application location(UTM coordinates). must be completed. Incomplete applications may be returned for Provide the property address of the well location if one exists. If more information. Applications ere evaluated in chronological it is the same as the mailing address, check the box next to the order. Please allow approximately six weeks for processing. well location address. This form may be reproduced by photocopying. Reproductions must retain margins and print quality of the original form. If filing online 5. A current deed for the subiect parcel must be attached. lithe see online filing instructional You may also save, print,scan and subject parcel is 35 or more acres, a complete metes and bounds email the completed form to: dwroermitsoniinestate.co.us type legal description or surveyor's plat map that references a DO NOT use this form for the registration of an existing well in section point is required to enable us to plot the parcel in our DO prior toMay 8,197 (use Form GWion2o. mapping system. If the parcel is less than 35 acres and gg(in a usesubdivision, a deed with metes and bounds legal description, FEES: This application must be submitted with the appropriate filing recorded prior to June 1, 1972 is required. Complete Items 5A fee. The filing fee for appilcatlons is$100. Exceptions are as follows: through 5E (5E is optional). If you answered NO to Item 5C 1)An application to replace or deepen an existing pernitted well that is please indicate who the landowner is. If you are under a contract in the same source (aquifer) which does not have a "-F"or"-R" suffix to purchase the subject property, please state this as well. If the after the original permit number is M. 2)Applications to register an parcel is inside the Denver Basin, the application must be in the existing well(use Form GWS-12), and replace or deepen the well(use name of and signed by, or their name entered by, the current Form GWS-44) into the same aquifer is $100 if submitted together. landowner. If filing online please see online filing instructions Fees are nonrefundable. Acceptable forms of payment are check or for how to submit deed and or legal description attachments. money order, payable to the Colorado Division of Water Resources. 6. See above comments under USES to determine those uses for Payment by Visa,MasterCard or Discover cards can be accepted by which you may qualify, and then check the applicable box or phone through the Records Office at 303.866.3581, boxes ISM::This form(GWS-44) is to be used when applying for a permit 7. The maximum pumping rate is limited to 15 gpm for most for the following types of uses: residential type well permits. The annual amount of water to be A. Ordinary household use inside one single-family dwelling withdrawn is a volume measured in acre-feet. One acre-foot (NO outside water use allowed): Generally,this is all that can equals 325,851 gallons. For ordinary household use inside one be approved on parcels less than 35 acres. single-family dwelling and no outside use,the annual amount will B. Ordinary household use in 1 to 3 single-family dwellings, be about 1/3 acre-foot. For ordinary household use in three irrigation of up to one acre of home garden and lawn, and single-family dwellings, one acre of home garden/lawn Irrigation, watering of domestic animals: Generally, permits can be and watering of domestic animals,the annual amount will be about approved on parcels of land of 35 or more acres, or in areas 3 acre-feet. For 100 head of livestock,the annual amount will be inside the Designated Basins, the Denver Basin, limited areas about 1,35 acre-feet. Please indicate the estimated depth of the on the Western Slope, and for subdivisions under a court- proposed well. The proposed aquifer for the well must be approved plan for augmentation that allow outside uses. Indicated if the well is to be located within the Denver Basin (the approximate area of the Denver Basin extends south from Greeley C. Livestock watering on farm, ranch, range, or pasture (on to an area east of Colorado Springs and from Golden east to parcels of 35 or more acres). Limon), the San Luis Valley, the Southern High Plains basin In ITEM INSTRUCTION : (numbers correspond with those on the Baca or Prowers Counties, or in areas where it is believed the front of this form) well will penetrate a confining layer. Aquifer information should be provided if known,for well locations outside of these areas. 1. The applicant is the entity for whom the permit is to be issued. Since the well owner is ultimately responsible for the use of the 8. The issuance of well permits may depend on the availability of well, their name should be in this area. The mailing address is another source of water, pursuant to CRS 37-92-602(6), such as where the applicant currently receives mail. water from a municipality or water district. (Statutes can be 2. Check all boxes that apply. If you check the box for Rooftop accessed through the CDWR web site.) precip. collection, you must also complete and submit Form 9. Check the applicable box, and complete or attach any additional No GWS-78. information as requested in this item. 3. Complete all boxes that apply. 10. Wells must be constructed by a Colorado licensed well driller, or under the "private driller" provision as defined in CRS 37-91- 4. You gagprovide a well spot location under the following is circumstances:(a)the location is decreed by a water court;(b)the 102(12). A listing of licensed well drillers/pump installers available at well will be inside the Denver Basin or other location where a site- hito:ilwaier.5tate.ce.usi aro a ndwaten B OE/Panes.-ucemsedCo n trac( specific well depth restriction will apply; (c)your application is for a ors.aspx permit to use an existing well. When a spot location is required, you must provide the county, % of the % section designation 11. The individual signing the application or entering their name(and (example:NE%of the SE%),section#,township, range,principal title if applicable) must be the applicant or an officer of the meridian, and either distances from section lines or a GPS location corporation/company/agency identified as the applicant or their (UTM coordinates). If providing a GPS location,the required GPS attomey. An authorized agent may also sign or enter their name unit settings must be as indicated on this form. Colorado on the application if a letter signed by the applicant or their contains two UTM zones (12 & 13), Zone 13 covers most of attorney Is submitted with the application authorizing that agent to Colorado. The boundary between Zone 12 and Zone 13 Is the sign or enter their name on the applicant's behalf. Payment must 108th Meridian (longitude). West of the 108th Meridian is UTM be received via phone if filing online at 303.866.3581 (Records Zone 12 and east of the 108th Meridian is UTM Zone 13. The Office)prior to processing the application. 108th Meridian is approximately 57 miles east of the Colorado- IF YOU HAVE ANY QUESTIONS please call the Colo. Division of Utah state line. On most GPS units, the UTM zone is given as Water Resources (303-866-3581), or the nearest Division Field part of the Easting measurement, e.g. 12T0123456. Check the Office in Greeley(970-352-8712), Pueblo(719-542-3388),Alamosa appropriate box for the zone. (719-589-6683), Montrose (970-249-6622), Glenwood Springs For all other applicants, you must provide the following (970-945-5665), Steamboat Springs (970-879-0272), or Durango minimum information: (a) the county, section#, township, range (970-247-1845), or refer to the CDWR web site at and principal meridian; and, (b) the subdivision lot, block & httn.//www.water.state.co.us for general information, additional filing/unit designations as applicable if in a subdivision. You do forms,and access to state rules or statutes. DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT rs 1555 Y 17TH AVE GREELEY, CO 80631631 WEBSITE: www.co.weld.co.us WI ADMINISTRATION (970) 304-6410 FAX(970) 304-6412 O PUBLIC HEALTH EDUCATION AND NURSING (970) 304-6420 FAX(970) 304-6416 o ENVIRONMENTAL HEALTH SERVICES (970) 304-6415 COLORADO FAX (970) 304-6411 THIS PACKET PROVIDES THE FORMS NEEDED TO APPLY FOR A PERMIT TO INSTALL AN INDIVIDUAL SEWAGE DISPOSAL SYSTEM WHEN ALL REGULATORY REQUIREMENTS CAN BE MET. ALL PERMIT APPLICATIONS MUST BE SIGNED BY THE OWNER/AUTHORIZED AGENT. NO PERMIT APPLICATIONS WILL BE ACCEPTED BY MAIL. PROCESSING TIME: Please allow FIVE (5)working days from the date of the inspection to process your permit. APPLICATION FORMS/FEES: The following forms must be submitted to schedule your inspection.A PERMIT WILL NOT BE ISSUED UNTIL THESE ITEMS ARE SUBMITTED. 00 1. COMPLETED INFORMATION PAGE: with appropriate fee of$750.00 for Residential, $850.00 for Commercial, or $100.00 for Minor Repair Permit. ( ) 2. ENGINEERING: Soil tests, geological report, engineered design less than(20) twenty years old(if necessary), AND site plan. TWO signed and stamped originals are required. ( ) 3. PARCEL NUMBER: This can be obtained from the Assessor's office at(970) 353-3845 ext 3650, or on the county website under property information and maps. ( ) 4. AUTHORIZATION FORM: Completed if applicant is not the property owner. ( ) 5. MAP TO PROPERTY. ( ) 6. OWNER'S NAME must be posted at site. Prior to permit issuance, a site inspection will be made. Please be sure the SITE is marked, and the location of the WELL or CISTERN and ABSORPTION SYSTEM are also marked with stakes or flagging. If we can't find your site, we cannot process your application! If you have any questions regarding the permitting process for individual sewage disposal systems, please call (970)304-6415. SEPTIC PERMIT INFORMATION FORM MIPSCam 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 3( 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.: I ��Z Z S 6 D D (12 DIGIT NUMBER) LEGAL DESCRIPTION: SECTION 2-Z TOWNSHIP 14.NI RANGE P 7`u ACRES i3 SUBDIVISION LOT BLOCK FILING THIS INFORMATION CAN BE OBTAINED FROM THE ASSESSOR'S OFFICE AT (970) 353-3845 EXT 3650 SITE ADDRESS t1 t wc. i • L`1 (� o DIItECTIONSTOSITE I/Z W�� 1U;Bet c � o �� S � PROPERTY OWNER: MAILING ADDRESS: CITY ST ZIP HOME PHONE: ( ) _WORK PHONE( ) FAX(—) EMAIL ADDRESS: I) APPLICANT NAME: VAwc,LJ{ Kv,w MAILING ADDRESS: I 33tt ?4. ck e . CITY `nC ST (O ZIP bSl6 HOME PHONE: ( ) — WORK PHONE(363) Z[6-%66 FAX O20) 2-7q-U(a9 EMAIL ADDRESS: I<%4 et: 4,):*.;), 4-lacer[ • e DESCRIPTION OF BUILDING(EX: HOUSE,MOBILE HOME,MODULAR,SHOP,OFFICE) 5 hop IF OBTAINING A REPAIR PERMIT,WHAT IS BEING REPAIRED? Z y NUMBER OF PERSONS IN FLOOD PLAIN AREA? NUMBER OF BEDROOMS PERCOLATION HOLES MUST BE MARKED FOR INSPECTION OR A$50.00 FEE WILL BE CHARGED BASEMENT PLUMBING YES,g), ' CENSUS TRACT BATHROOMS: FULL /. j' %YE PUBLIC WATER SUPPLY SS'S. NAME PRIVATE WATER SUPPLY E N EL /CI PERMIT# 04 :10 DEPARTMENT OF PUBLIC HEALTH&ENVIRONMENT Kit 1555 N. 1r Avenue Greeley,eyy CO, CO 80631 WEBSITE: www.co.weld.co,us ADMINISTRATION: (970) 304-6410 FAX: (970) 304-6412 PUBLIC HEALTH EDUCATION & NURSING: (970) 304-6420 FAX: (970) 304-6416 ENVIRONMENTAL HEALTH SERVICES: (970)304-6415 COLORADO FAX: (970) 304-6411 AUTHORIZATION FORM RE: [ ] PERMIT APPLICATION n I.S.D.S. EVALUATION n SALE OF PROPERTY n WA(TER SAMPLE t I e4vay' ?V.;txt t,e, represent kc; Ykailc for the property (Agent/Applic it) (Owner) located at mi `lA i2C e 6 cup L'C I I LEGAL DESCRIPTION: SEC 2-Z TWN Li N RNG (2&I t> SUBDIVISION NAME: CIA LOT BLK I can be contacted at the following phone#'s: Home Work $c )40 J 6>L>L' Fax# Rzo ZT9-01I1 The property owner can be contacted at the following phone#'s Home S2"'e Work Fax# Correspondence mailed to(only one): X Agent/Applicant C Property Owner DATE 3- 28 - lL( OWNER'S SIGNATURE ill? PLEASE DRAW A MAP TO YOUR PROPERTY. N o- o� V 3 ly / clo- S(te // C Hello