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HomeMy WebLinkAbout1.08 Water Supply12. Water Supply and Distribution Plan (pursuant to Section 4-203.M) Introduction An on-site well was constructed in 2013. A "Permit to Use an Existing Well" was issued by the Colorado Division of Water Resources (DWR) on February 25, 2016. Evidence of this is Well Permit #300237, included in this application. The on-site well is to be used to just provide water for Lot 1. A 4 -hour pump test was performed on the well in 2017 by Samuelson Pump Co., Inc. The pump test yielded a production rate of 1.3 gallons per minute (gpm). According to the pump test report prepared by Samuelson Pump Co., Inc., "...at this time the well will produce 1,872 gallons per day (gpd). Storage would be required for the well to provide water for a house. This well could provide water for a house." A copy of the pump test report is included in this application. Image 6. On-site well The lot owner(s) will be responsible for developing plans, documents and specifications for the single dwelling unit and associated improvements to be constructed on Lot 1 and for submitting those to the County at the time of building permit. Therefore, it is not possible to submit a water supply and distribution plan specific to improvements on Lot 1 with this application. A request for a waiver of the submission requirements of Section 4-203.M is included in this application. The lot owner(s) will be responsible for preparing and submitting a water supply and distribution plan to the County at the time of building permit. The water supply and distribution plan is to be prepared in accordance with the applicable requirements of Section 4-203.M. Estimates for on-site water demands are included below to demonstrate the feasibility of the existing well providing water to the Lot 1 development scenario previously described in this application. Estimated Potable Water Demands The estimated potable water demand for a single dwelling unit on the proposed lot is provided below. Pursuant to Section 4-203.M, average daily water demand was calculated using Garfield County's Single - Family Equivalent (SFE). The County defines 1 SFE as being equivalent to 350 gallons of water per day, regardless of the type of uses. Table 17 presents the daily, monthly and annual demands for potable water assuming a maximum build out of one (1) single-family home on Lot 1. 63 Table 17. Estimated Potable Water Demand Month Days per Month Estimated Potable Water Demand (for 1 single-family home Gallons per Day Gallons per Month Acre -Feet per Month January 31 350.00 10,850.00 0.03 February 28 350.00 9,800.00 0.03 March 31 350.00 10,850.00 0.03 April 30 350.00 10,500.00 0.03 May 31 350.00 10,850.00 0.03 June 30 350.00 10,500.00 0.03 July 31 350.00 10,850.00 0.03 August 31 350.00 10,850.00 0.03 September 30 350.00 10,500.00 0.03 October 31 350.00 10,850.00 0.03 November 30 350.00 10,500.00 0.03 December 31 350.00 10,850.00 0.03 Estimated Total Annual Demand 127 750.00 0.39 Estimated Irrigation Water Demands In accordance with Well Permit #300237, the on-site well can be used to irrigate up to one (1) acre of "home gardens and lawns." Data from the Colorado Division of Water Resources' (DWR) Guide to Colorado Well Permits, Water Rights, and Water Administration (2012) were used to calculate the approximate irrigation water demands for landscaping on the proposed lot. For the purpose of this application it is estimated that the lot owner(s) will install 5,000 square feet (0.11 - acres) of landscaped/lawn area requiring irrigation. However, based on an analysis of the landscaping installed by adjacent property owners, it is anticipated that the lot owner(s) will install less than 5,000 square feet of landscaping. The DWR estimates that for every 1,000 square feet of lawn area, 0.05 acre-feet of water is used per year. Table 18 presents the estimated daily, monthly and annual demands for irrigation water assuming 5,000 square feet of lawn area to be irrigated on Lot 1. Table 18. Estimated Irrigation Water Demand Month Days per Month Estimated Irrigation Water Demand (for 5,000 square feet of landscaped/lawn area) Gallons per Day Gallons per Month Acre -Feet per Month January 31 0.00 0.00 0.00 February 28 0.00 0.00 0.00 March 31 0.00 0.00 0.00 April 30 387.92 11,637.54 0.04 May 31 375.40 11,637.54 0.04 June 30 387.92 11,637.54 0.04 July 31 375.40 11,637.54 0.04 August 31 375.40 11,637.54 0.04 September 30 387.92 11,637.54 0.04 October 31 375.40 11,637.54 0.04 November 30 0.00 0.00 0.00 December 31 0.00 0.00 0.00 Estimated Total Annual Demand 81,462.75 0.25 64 Fire Protection Demands The subject property is located within the service area for the Carbondale & Rural Fire Protection District (CRFPD). CRFPD has indicated that they will provide fire and emergency medical services to the subject property. The applicant understands that this application will be referred to the CRFPD for review and comment. The applicant will address the recommendations of the CRFPD, to the best of their ability, once they have been received. Without having detailing information about the improvements to be constructed by the lot owner(s) some of the recommendations from the CRFPD may need to be deferred to the time of building permit. A request for a waiver from the submittal requirements of Section 4-203.M.1.b is included in this application. Summary of Estimated Water Demands Table 19 below shows the estimated total daily, monthly and annual water demands on the lot. The Table also presents the estimated average and maximum daily and monthly water demands. Table 19. Estimated Total Annual. Average and Peak Daily Water Demands Month Days per Month Total Water Demand (for 1 single-family home and 5,000 square feet of landscaped/lawn area) Gallons per Day Gallons per Month Acre -Feet per Month January 31 350.00 10,850.00 0.03 February 28 350.00 9,800.00 0.03 March 31 350.00 10,850.00 0.03 April 30 737.92 22,137.54 0.07 May 31 725.40 22,487.54 0.07 June 30 737.92 22,137.54 0.07 July 31 725.40 22,487.54 0.07 August 31 725.40 22,487.54 0.07 September 30 737.92 22,137.54 0.07 October 31 725.40 22,487.54 0.07 November 30 350.00 10,500.00 0.03 December 31 350.00 10,850.00 0.03 Estimated Total Annual Demand 209,212.75 0.64 Estimated Average Daily Demand 572.11 17,434.40 0.05 Estimated Maximum Daily Demand 737.92 22,487.54 0.07 As noted in the pump test report, prepared by Samuelson Pump Co., Inc., on-site water storage facilities may be required for Lot 1. If necessary, the lot owner(s) will be responsible for including plans, documents and specifications for such facilities with the water supply and distribution plan to be submitted to the County at the time of building permit. 65 Water Quality Standard Bacteriological Water Tests performed on the well on November 29, 2017. These tests indicated that Total Coliform and Fecal Coliform were both absent. Copies of these tests are included on the following page. A Raw Water Quality Test was performed by Zancenella & Associates, Inc. on the well on October 24, 2017. This test identified no issues with the well's water quality. A copy of that test is included in this application. Well Permitting The DWR permitted the existing well for a parcel of 35 or more acres. Approval of Lot 1 will result in a parcel smaller than the one originally considered for the existing well permit. Through correspondence with Dwight Whitehead, at the DWR, it is understood that the existing well may need to be re -permitted in accordance with DWR Policy 2011-1 and current law as it applies to the newly created lot on which the well will be located. Standard Bacteriological Water Test Results STANDARD BACTERIOLOGICAL WATER TEST ASPEN CONSOLIDATED SANITATION DISTRICT 04010 SERVICE CENTER DRIVE 41V fl ASPEN, COLORADO 91611 )f4 l yu% "! (UO) 925-7292. Exl. TOJ MSID1 &MPLE L4ltltN: DATE iki±tirwiE . �, 40, 9L,PPLV SJT� iii l o1latTy (CJJ•efcl { I DCMMUAm SUPPLY 1 1 I RCN COMMI1NIT' ( ( OTCR W1BLIc I KPRIVATF '•1IOTt IP ALL I1WOAMATION REMARKS: RETURN TO ACDRES. CrTVSTATE BAWLER EVW- — ua,l ) ROUTIm dsmtrrioN SYSTEM SUPPLY 1 CHECK SAMPLE ( ) FIXES WATBi ) RA c )4 mum ( ) MARGE } SPECIAL REPOSE SAMPLE 16 NOT BDrPUBD, Pt MIME PL WILL BE DISCARDED. PHONE _ e_ - SEE INSTRUCTIORS ON BACK PAGE - Sat �ERSE FOR TIME LIMITATK»15 SAMPLING 1NSTR ICTIcNs AND DERNITIONs OFF STANDARD BACTERIOLOGICAL WATER TE87 ASPEN CONSOLIDATED SAM 'MON DISTRici 0400 SERVICE CENTEN DRIVE ASPEN. COLORADO 61611 (e70) 9%64747, Est, 109 (� PWS ID . Simple LolyEm A SAMPLED/Caw, Q44TTTEI+1..2 tJJ. ( /U; 3¢"L MPV („ ^ 1 cOUNfY Vr •@IL�r'elSL SORER (Si/04 . Mr I i MOIUNITY SUPPLY { ) MORE DISTRIBUTION SYSTEU SUPPLY ! 1 NON OCVAUNITY ( I USDAI i h IDIESSWATER 1 ) OTR mac PPAW 2 ( 1 SW1EACE I �(i PRIVATE ALL INFDRNATIDN rs 1001" c1A+PLIEO, THE SAMPLE WILL EC DI®CAPo eo. REMARKS _Cl,,. f FIETIIIW TCS-�Y� CCS ADDRESS /34X-. ! 7 cITY•STATE 6.,'1a4/ 5-p!)1-..tr Co 7576.50 - AO* Icr ja % -x 9'` ?- 9/Wr - SEE INSTAUCTIONS ON RACK PAGE - SEE• Ev=RSE FOrI TARE I IMWTATIpNS, SAMPLING INSTRUCTIONS AAI, LeFINITIO'Is 66 RESULTS DIRECT COUNT: COLONIES C- VITABI FORTE ADJUSTED co.I4T• ■. ONIES/1 TEFTALCOLIFOA ABSE,: PRESENT FECAL COLIED ABSENT/ PRESENT LTR 21 LTD 411 BOB MPN COCIaDRW100ML PRESENCE OF COISoFIMS INDICATE NON. Cak4PUANCE WITH LRNIMIIM DRINKING WATER STANDARDS LJ Conplgice allon•Cnmphanca 1 kNslk �rl'1 UNSUITABLE FOR TES .rEABRANE PILTE�, LTB 24 LTB IB Bp@ MPN C LFLIFORAVICO 1L PRESENCE OF COLIFORMS INDICATE NON- COMIRJANCE WITH MINIMUM DI:MONO WATER STANDARDS. Q Compliance 0 NurCompliulop ] InY.l0 Samuelson Pump Co., Inc. Pump Test Report September 19. 201 i Wendy McNulty 77447 County Road 100 Carbondale. Co. 81.523 ATTN: Wendy On 7/31/17, a well test was conducted on a well on the McNulty Property on Cottonwood Pass Rd. The following information was obtained; Well Depth Casing Size Standing water level Total test time Drawdown to Production is 200' (7x5)" 99.1' 4 Hours pump intake 1.3 GPM This test was conducted with Test pump. The well water level recovered back to 142.82 in 60 Minutes. At this time the well will produce 1872 gal. per day. Storage would be required for the well to provide water for a house. This well could provide water for a house. lfyou have any questions please call me. Raun Samuelson at 970-945-6309. Sincerely: i Raun L Samuelson Samuelson Pump Co. P.O. Box 297 • Glenwood Springs, CO 81602 • (970) 945-6309 • Fox (970) 947-9448 t4otor Systems • Sales Service & Instoflcthnn Zancenella & Associates, Inc. Raw Water Quality Test Results tecto-rd 60) Pk" c)\.1/4. 151,14_t V2,01 „34 allne mown Is 01•1~damsaMie• ••• Owlet.,• 68 IMIEURINART Tow Mn AO*. Woof 4 y I... --..._ m - Cog Oty Amtyst. -- _- Illi iii gum Maiidtv Wadi. WO - -�+'�t 1 i iuw.. YuE 11.41. M. �!op..� mow n..y . P'nro E605 0 817 eG[ _ .dam aW7i OLl ea 1_ epi 80l 07d Pro _ Tsai - Coip _ ay. 0 .. fir 4awikin 'i bapwc .s.�.e . _ . -moi-_ 0013 - n.1wt "!t 0.01 Oar 1 1 'air 4 - 8A... maw Pr.1.y saik ci WO mat ►w ..9_ I neo opt 0Al 94 149 41040 74. 17000 �P.p '!aA +S.s1r !...a. ^Il Prl.17 Pr..ry 001 001 9 7]tgp.' I14 maggot 10 71.i Mer +m5. 5wwlal•7 07 1.2 -O 30 t1 F2 t 0 Mail 51r1P. Pmrwy 40020 90001 40150 Post 11S IS W. [YsJ/e j�llt NOR &.o w.l� yr _ _ _ agg. 00 0005 otos 00005 4197 in. DOW VOL 1�1 :N:9 iot oa '54 09 WANA 0 0000 N.a 14 S5 *mu rw Yrws Dhow 1"..e _ 014 Pm 1909OM.w ----4=-- -irk Ides_ �rdt Walla -001 10 11 IOW Solo. 9.rnr11Py Tb. 0 s0 P,u. _ -014 - 00910 P_y. 'Po.s �,9 0.Ml 0.05 l0 Ps y ..=.,.Ill 19 -__ .�aW 74 71 ZlOwlr Cyw.l. "Numb' I00 *NNW IMO--n. s.a.11lr P07 .0t ..r. . CR 00 0005 at: SOL air 250 r5.. 070 1V.. - A*pR 919K 02 1oa 217 Vilialm Off irPllµ li agog 9 m2.y 17 00017 00 _ 7�'+...o 3 X41 Ogogag logo MIS. Pr...7 POW,. Oft *M _ _. llra.. 901 0Oa dA _ 461. - KIll_ liprilta . Ol-0. Pres 11 "'�.' r_J#I/q. io.wgo WM CAwnnlp Now 1105. taco, 5 772 w, `KA 1149 » '7 1i/Oks7 T!1 Od9Uwoo.r Hl/F. 1..w w04. COLO, 5 202 *A billow L'ti0w.i VW OvaloY/ NOw -,-759- 1 VOL MN N9 Vol 0 71 Corasaloa .'aT• IVa. E po1,R9Y� Rom i 1 "91 11'00 ]m P.o. mama R,. Granary m'* among "8...11 .lag 14 tJ:a 1 70T 77 17 Lona. Pao Woe C11.l...y isms Ns. deli 0*ww.O b.1 2 194 wa 00 00 Fw DN 1104 r7ls.sl Was Smwd.7 tams, 10* Awl 0.01 10 9 290 3t 5F • 0 Pass 0 Goat a9r. 91.. p 'P.*0 Pr p ICA u 29 0 Pan >• 5t 7. Gmsle. *0..s _ _ Ads A.NO.lde Pn..y 44 040I*^i.Laso Pots Homan 770 W4Wb 101f11sgYo Prwl.y Pawa.y Irl FIit 01 or .1 . s0 MAW* TOM 'Pea A.O.n 72. hada= Pwbar.514. _ 57 0 0 ium L9yif Fe. -uEww1 0 s.su 51.da+ogo Paw." post WPM 0001 05000 Ns. allne mown Is 01•1~damsaMie• ••• Owlet.,• 68 Well Permit issued by the Colorado Division of Water Resources Form No. OFFICE OF THE STATE ENGINEER GWS -25 COLORADO DIVISION OF WATER RESOURCES 818 Centennial Bldg., 1313 Sherman St., Denver, Colorado 80203 (303) 866-3581 APPLICANT SARAH MCNULTY 7747 COUNTY ROAD 100 CARBONDALE, CO 81623- (970) 963-4363 PERMIT TO USE AN EXISTING WELL EXST WELL PERMIT NUMBER 300237 DIV. 5 WD 38 DES. BASIN MD APPROVED WELL LOCATION GARFIELD COUNTY SW 1/4 SW 1/4 Section 33 Township 6 S Range 87 W Sixth P.M. DISTANCES FROM SECTION LINES 854 Ft. from South Section Line 1152 Ft. from West Section Line UTM COORDINATES (Meters,Zone:13,NAD83) Easting: Northing: ISSUANCE OF THIS PERMIT DOES NOT CONFER A WATER RIGHT CONDITIONS OF APPROVAL 1) This well shall be used in such a way as to cause no material injury to existing water rights. The issuance of this permit does not ensure 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. 2) The construction of this well shall be in compliance with the Water Well Construction Rules 2 CCR 402-2, unless approval of a variance has been granted by the State Board of Examiners of Water Well Construction and Pump Installation Contractors in accordance with Rule 18. 3) Approved pursuant to CRS 37-92-602(3)(b)(II)(A) as the only well on a tract of land of 40 acres described as the E 1/2 of the SW 1/4 of the SW 1/4, and the SW 1/4 of the SW 1/4 of the SW 1/4, Sec. 33, and the SE 1/4 of the SE 1/4 of the SE 1/4, Sec. 32, all located in, Twp. 6 South, Rng. 87 West, 6th P.M., Garfield County. 4) Approved for the installation of a pump in, and the use of, an existing well, constructed on May 21, 2013, to a depth of 190 feet, under permit no. 290484 (canceled). Issuance of this permit hereby cancels permit no. 290484. 5) The use of ground water from this well is limited to fire protection, ordinary household purposes inside not more than three (3) single family dwellings, the watering of poultry, domestic animals and livestock on a farm or ranch and the irrigation of not more than one (1) acre of home gardens and lawns. 6) The pumping rate of this well shall not exceed 15 GPM. 7) The return flow from the use of this well must be through an individual waste water disposal system of the non -evaporative type where the water is returned to the same stream system in which the well is located. 8) This well shall be located not more than 200 feet from the location specified on this permit. NOTE: Expired permit nos. 208676 and 278871 were previously issued for this applicant, in this 1/4, 1/4. NOTE: Parcel Identification Number (PIN): 23-2189-333-00-037 NOTE: Assessor Tax Schedule Number: R050291 (totaling 199.70 acres) APPROVED DMW Receipt No. 9503856 t'�,k Wolfe- by 9.. �-✓� State Engineer By DATE ISSUED 02-25-2016 EXPIRATION DATE N/A 69 !+`S423es-6/73oo237 WELL CONSTRUCTION AND TEST REPORT STATE OF COLORADO, OFFICE OF THE STATE ENGINEER FOR OFFICE USE ONLY =C/;D RECEIVED WAR 1 16 AUG'G(� E — Z ZWvvq �rE RCE.s coteNEER WATER RESOURCES COLO 1 290484 CD • WELL PERMIT NUMBER 3 Z3 7 2. Owner Name(s): Sarah McNulty Mailing Address: 7747 County Road 100 City, State, Zip : Carbondale, Co 81623 Phone #AWRilaVtice_igl WALL LOCATION AS DRILLED 3 SW 1/4 SW 1/4 Sec: 33 Twp: 6 S Range: 87 W 6th PM DISTANCES FROM SEC. LINES ft. from Sec. line and ft. from Sec. line OR Easting: 3 17 708 Northing: 43 72 831 SUBDIVISION: LOT: BLOCK: FILING (UNIT): STREET ADDRESS AT LOCATION 4 GROUND SURFACE ELEVATION ft. DRILLING METHOD Air Rotary DATE COMPLETED: 5/21/2013 TOTAL DEPTH: 190 DEPTH COMPLETION: 190 5. GEOLOGIC LOG 6. HOLE DIAMETER (in) FROM (ft) TO (ft) Depth Type of Material (Size, Color, and Type) 9.0 0 42 000-035 Clays, Cobbles 6.5 42 190 035-190 Maroon Formation (Transition Zone) 7. PLAIN CASING OD (in) Kind Well Size From (ft) To (ft) 7.0 Steel 0.240 -1 41 5.5 Steel 0.188 36 100 5.5 Steel 0.188 150 190 PERF. CASING : Screen Slot Size 5.5 Steel 0.188 100 150 Water Located: 110+ Remarks : 8. Filter Pack Material : Size : Interval : 9. Packer Placement Type : Depth : 10. GROUTING RECORD Material Amount Density Interval Placement Cement 7 sks 6 gal/sk 10-40 poured 11. DISINFECTION : Type : HTH Amt. Used : 3 oz. 12. WELL TEST DATA : ( ) Check Box If Test Data Is Submitted On Supplemental TESTING METHOD : Air Compressor Static Level : 104 ft. Date/Time Measured 5/21/2013 Production Rate 5 gpm Pumping Level: Total ft. Date/Time Measured 5/21/2013 Test Length : 2 hours Test Remarks: 13. f have lead the, notennns made herein end know the mntnnx dread; end that they ere tate to my knowledge. (Pens, not to Section 24.4-1.4 (13)(a) CRS, the mating of false statements oar blares Pet? m the sa od dgme anlwmabk az a oMto 1 mtsdemunor.) CONTRACTOR Shelton -grilling Corp. Phone : (970) 927-4182 Mailing Address : P.O. Box 1059 Bas Co 1621 Lic. No. 1095 Name / Title (Please Type or Print) Wayne Shelton / President Sign Date 5/27/2013 70 COLORADO DIVISION OF WATER RESOURCES • DEPARTMENT OF NATURAL RESOURCES 1313 SHERMAN ST., RM 818, DENVER, CO 80203 phone — info: (303) 866-3587 main: (303) 866-3581 fax: (303) 866-3589 httpJ/www.water.state.co.us B. # of acres in parcel C. Are you the owner of this parcel? 40 OYES 0 NO (if no - see instructions) D. WII this be the only well on this parcel? YES 0 NO (if no - list other wells) RESIDENTIAL Note: Also use thls form t Form GWS -44 (07/2009) Water Well Permit Applicatlutt Review form instructions prior to completing form. The form must be completed in black or blue Ink or typed. 1. Applicant Information Nene of applicant Sarah McNulty Mailing address 7747 County Road 100 City Stale Carbondale Co _. -.._- Telephone* ! E --mail (optional) P4 963 c1363 Zip code 81623 ffice Use Only RECEIVED MAR 0 2 20f •r4AfEit RESOURCES 2. Type Of Application (check applicable boxes) ❑ Construct new well ❑ Replace existing well ❑X Use existing welt 0 Change or increase use 0 Change source (aquifer) 0 Reapplication (expired permit) 0 Rooftop precip. collection 0 Other: 3. Refer To (if applicable) Well permit 290484 Designated Basin Determination ft Water Court case # Well name or RECEI FD RECEIVED FEB 0 5 '15 WATER RESOUROa 2 8 '14 STATE 'ENGINEER GLENW°iRATEIR RESOURCEL STATE EN GG i NNOEE R STATE OLO ENGINEERERECE>t/�T re-p.lt,�.S V q 6. Use Of Well (check applicable boxes) - - See instructions to det#nine tTBe(9fo5rl h u 0yy u f O A. Ordinary household use in one single-family dwelling (no outside use) Q B. Ordinary household use in 1 to 3 single-family dwellings: Number of dwellings: 3 x❑ Home garden/lawn irrigation, not to exceed one acre: area irrigated 1 sq. ft. D acre 0 Domestic animal watering - (non-commercial) ❑ C. Livestock watering (on farm/ranch/range/pasture) 4. Location UT I'roposea wet! (important! see instructions) County Garfield ' SW 1f4 of the SW rf4 Section Township Nor S Range E or W Principal Meridian 33 6 87 ❑❑X 6th Distance of well from section lines (section lines are typically not property lines) Ft from©N❑S Ft. from ❑E❑W ---- c For replacement wells only - distance and direction from old well to new well feet direction Well location address Include City, State, Zi Check ewell ay��rarss is same a3Vom.1T TM e -C-414 Optional: GPS well location info ation in UTM formal. GPS unit settings are as follows: Format must be UTM 0 Zona fz o ❑x Zane 13 Easting:3 17 708 Units must be Meters Northing:43 72 831 Datum must be NADBS Unit must be set to true north Wes GPS unit checked for above? 0 YES Remember to set Datum to NAD83 7. Well Data (proposed) Maximum pumping rate 15 Total depth 190 gpm feet Annual amount to be withdrawn 3.0 Aquifer Tributary acre-feet 8. Water Supplier Is this parcel within boundaries of a water service area? DYES 0 NO If yes, provide name of supplier: 9. Type Of Sewage System • Septic tank / absorption leach field O Central system: District name: 0 Vault: Location sewage to be hauled to: /"0 Other (attach copy of engineering design and report) %1o. Proposed Well Driller License #(optional):1095 5. Parcel On Which Well Will Be Located (YOU MUST ATTACH A CURRENT DEED FOR THE SUBJECT PARCEL) A. You must check and complete one of the following: ❑ Subdivision: Name Lot Block Filing/Unit O County exemption (attach copy of county approval & survey): Name!# Lot # ❑ Parcel less than 35 acres, not in a subdivision, attach a deed with metes and bounds description recorded prior to June 1, 1972, and a current deed ❑ Mining claim (attach a copy a the deed or survey): Name/# O Square 40 acre parcel as described in Rem 4 ❑ Parcel of 35 or more acres (attach a metes and bounds descriptio, or survey) ❑ Other 11. Signature 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. 24-4-114 (13)(a). I have read the statements herein, know the contents thereof and state that they are true to my knowledge. .. Sign here (Muss be oryginal signature? Date Print name &tale �..�( 1�1�41 I 1 1�Jc)LT 1 Office Use Only i°,/z/% (per l "�6 r USGS ma/p name S4 r F / 1 9/�D�"r/7 n�Jn e /�, $ r e elev. / c P 4 &f Receipt area I oonllyy t� !� T� vt • ✓ /a/� 97 cp,f osis.///3 c / 9 f -•,o (attach metes bounds description or survey end suppreting documents) �sN; 3 Z/639-333-00-0?7!A4S0zgl (/(0/4/;,-5 71