Free GWS-76, Water Supply Information Summary - Colorado

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: