FORM NO. GWS-76 02/2005
WATER SUPPLY INFORMATION SUMMARY
STATE OF COLORADO, OFFICE OF THE STATE ENGINEER
Phone Info (303) 866-3587 1313 Sherman St., Room 818, Denver, CO 80203 Main (303) 866-3581 Fax (303) 866-3589 http://www.water.state.co.us
Section 30-28-133,(d), 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: 3. NAME OF EXISTING PARCEL AS RECORDED: SUBDIVISION: 4. TOTAL ACREAGE: 5. NUMBER OF LOTS PROPOSED A. Was parcel recorded with county prior to June 1, 1972? If yes, describe the previous action: 7. LOCATION OF PARCEL Include a map delineating the project area and tie to a section corner. 1/4 of the Principal Meridian: 1/4, Sixth Section New Mexico , Township Ute Costilla Easting: Northing: N or S, Range E or W YES or NO YES or NO , FILING (UNIT) , BLOCK PLAT MAP ENCLOSED? , LOT YES or NO
6. PARCEL HISTORY Please attach copies of deeds, plats, or other evidence or documentation. B. Has the parcel ever been part of a division of land action since June 1, 1972?
Optional GPS Location: GPS Unit must use the following settings: Format must be UTM, Units Zone 12 or Zone 13 must be meters, Datum must be NAD83, Unit must be set to true N, 8. PLAT Location of all wells on property must be plotted and permit numbers provided. Surveyor's Plat: YES or NO If not, scaled hand drawn sketch: YES or NO 9. ESTIMATED WATER REQUIREMENTS 10. WATER SUPPLY SOURCE
USE WATER REQUIREMENTS Gallons per Day HOUSEHOLD USE # COMMERCIAL USE # of units of S. F Acre-Feet per Year EXISTING WELL DEVELOPED SPRING
NEW WELLS PROPOSED AQUIFERS (CHECK ONE) ALLUVIAL UPPER DAWSON LOWER DAWSON DENVER UPPER ARAPAHOE LOWER ARAPAHOE LARAMIE FOX HILLS DAKOTA
WELL PERMIT NUMBERS
IRRIGATION #
of acres
OTHER:
STOCK WATERING # OTHER: TOTAL
of head
MUNICPAL ASSOCIATION COMPANY DISTRICT NAME LETTER OF COMMITMENT FOR SERVICE YES or NO WATER COURT DECREE CASE NUMBERS:
11. WAS AN ENGINEER'S WATER SUPPLY REPORTDEVELOPED? (This may be required before our review is completed.) 12. TYPE OF SEWAGE DISPOSAL SYSTEM SEPTIC TANK/LEACH FIELD LAGOON ENGINEERED SYSTEM (Attach a copy of engineering design.)
YES or
NO IF YES, PLEASE FORWARD WITH THIS FORM.
CENTRAL SYSTEM DISTRICT NAME: VAULT LOCATION SEWAGE HAULED TO: OTHER: