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HomeMy WebLinkAboutpitkin.eh.264316200020 (2013)(2)Document Layout (From Most Recent to Oldest Permit) Permit Application Log Sheet/Notes & Photos Communications As -built Design Engineer Design Soil Information Floor Plans Water Permit & Information Land Use Approvals Second System on property Third System etc (All relevant older documents in the same order as above) (A red sticker will be placed on both sides of the file tab when doc. is scanned) O�1+S�SJ ONSITE WASTEWATER TREATMENT SYSTEM (OWTS) CONSTRUCTION PERMIT 76 Service Center Rd. Aspen, CO 81611 %V 0 Phone: 970.920.5070 Fax: 970.920.5374 Permit #: 0015.2013.powt Parcel ID A 2463-162-00-020 Permit Issued: ❑NEW CDU ®REPAIR ❑REMODEL/ADDITION ®TANK ONLY ❑FIELD ONLY ❑AMENDMENT Owner(s): John and Kathleen Buck Property Address: 260 Liberty Ln Legal Description: Size of Lot: Acres Size of Building: 1554 Sq. Ft. Detached Accessory Unit: DYES ONO Size of Accessory Unit: system is designed for: 3 bedrooms Designed By: Phone #: Fax #: Project #: Mailing Address: Email Address: Dated: Perc Rate: N/A Profile Hole Depth: Depth to Groundwater or Bedrock: Minimum Tank Capacity: 844 gallons Minimum Absorption Area: N/A Permit Conditions: Sq. Ft. This OWTS Construction Permit is approved on the condition of compliance with the engineer design as submitted with the application and the specifications cited above. Changes must be approved by this Department and the engineer prior to construction. This permit is for the replacement of a failed OWTS tank and cast iron pipe. The cracked tank was identified during the use inspection process. The tank shall be a 1000 gallons septic tank with an effluent filter and a minimum of 5 feet to the residence. The existing tank shall be pumped (if needed) and properly abandoned by removing, crushing, or backfilling. This Permit must be kept on-site during installation. The engineer must do a final inspection of the Installation and submit an "as -built' letter to this Department within 30 days of the final inspection, unless a longer period of time has been agreed upon, in writing. This Department must also be called for the final inspection with a minimum of 48 hours notice. Minimum horizontal distances between components of the system and physical features shall conform to the requirements of the Pitkin County OWTS Regulation. This Permit is conditioned upon the property owner(s) providing for regular inspection, cleaning, and maintenance of the system by qualified personnel, in accordance with the manufacturefs recommendations and the requirements of the Pitkin County OWTS Regulation. Issuance of this OWTS Construction Permit does not constitute a guarantee, warranty, or representation by the Department that the system will operate property or will not fail. Issuance of this permit does not imply compliance with Pitkin County building and/or land use regulations, nor guarantee issuance of building and/or land use permits. THIS PERMIT IS EXPRESSLY CONDITIONED UPON COMPLIANCE WITH ALL REQUIREMENTS OF THE PITKIN COUNTY OWTS REGULATION, INCLUDING BUT NOT LIMITED TO THOSE CONDITIONS SPECIFIED ABOVE. Plans and specifications for the proposed OWTS have been reviewed and are considered satisfactory. Permission is hereby given to the property owner(s) to perform the work indicated in accordance with the Pitkin County OWTS Regulation. This Permit will expire 1 year from the date of issuance unless construction on the system has commenced. An "as -built" drawing must be submitted and approved by EH before final approval of the system will be issued. Issued By: Date: 05/23113 Expires: M2112111e 0 L;Of*0 L3, pOwT D ONSITE WASTEWATER TREATMENT SYSTEM (OWTS) E ya CONSTRUCTION PERMIT APPLICATION 76 Service Center Rd - Aspen, CO -81611 Phone: 970.920.5070 Fax: 970.920.5374 Parcel ON (available from the Pitkin County Assessors Office company: City, State, Zip h AspaCell Phore' Fax Nu -222, ^( 8705205160 or at www .oitkinassessor orale W - `6 -2 - 00 - 07-0 Purpose of Permit: ❑ NEW ❑ REPAIR DUE TO FAILURE ❑ REMOOEL/ADDITION TANK ONLY ❑ FIELD ONLY Cost o1 System Repair or RemodeUAdddlon (approxtmate): Siza a Bu" square feep: Number of Potential Bedrooms: Property Address: Detached Accessory UnR7 YES NO ❑� �t L Number of Paennal Bedrooms In or Fixture list for the Accessory Unit Lot: Block: Filing Subdivision'. Water Source PRIVATE WELL ❑ SURFACE WATER ❑ SPRING ❑ OOMMUNRY/%1BUC WATER SysTEM Name of Communky/Public Water System (if applicable): Property Owner(s)': Email Address' Engineemp Firm: Job Number Phone Number. Fax Number Malang Address: City. State. Lp. s Mailing Address'. City, Sl e, Zip'. t ir�etoo H0rr� p 490-q Builliness Pircri RIL ,. r.0/IrBCt %nrrYalAr/M TIICI aY nm —au yW thehla a signing( Primary Contact ParsoN icant (no not owner): Contact/Applicant Marlingiv- 17 -2.61 N Milli Seel company: City, State, Zip h AspaCell Phore' Fax Nu -222, ^( nese Phone. Email Atldress: - BuN ing Pamdt ar (d applicable)'. La Sim (in acres). Siza a Bu" square feep: Number of Potential Bedrooms: Detached Accessory UnR7 YES NO ❑� Size W. Accessory Unit (square feet) Number of Paennal Bedrooms In or Fixture list for the Accessory Unit Water Source PRIVATE WELL ❑ SURFACE WATER ❑ SPRING ❑ OOMMUNRY/%1BUC WATER SysTEM Name of Communky/Public Water System (if applicable): Engineemp Firm: Job Number Phone Number. Fax Number Malang Address: City. State. Lp. PLEASE READ BEFORE SIGNING: I certlfy that the above IMonnallon Is complete and accurate and that I have provided complete and accurate Information in all of the documents Included In my application package. I acknowledge that EH/NR may revoke any permit I am Issued if my application Is found to contain any Inaccurate, false, or misleading Information. I understand that no construction may be undertaken on an OWTS until an OWTS Construction Permit is Issued. Owner Signet a Regwred' - Date Applicaa,Bgnature s� >7 Date: FOR OFFICE USEONLY Received by EStaff: File & RaerJptt Dale: L' 1 d --r c -T 7'�Orf mTFI Ir gTl.ZS'bTf'�"P�i100� w�el z 3 co t V O T 0 0 CBO Inc. 33 Four Wheel Drive Road Carbondale, CO 81623 Cell) 970-309-5259 Office) 970-704-0484 caria.ostberg@gmail.com June 12, 2013 John and Kathleen Buck c/o Sherman and Howard LLC. 201 N. Mill St, Ste 201 Aspen, CO 81611 Installation Observation — septic tank 260 Liberty Lane Pitkin County, Colorado OWTS Construction Permit Number 0012.2013.powt John and Kathleen, 0 ALL SERVICE septic, LLC observed the installation of the new septic tank at 260 Liberty Lane on June 12, 2013. Holmes Excavating installed the septic tank. The installation included a 1500 -gallon, two-compartment Roth® septic tank. Inlet and outlet tees were installed, with an effluent filter on the outlet tee. Risers will bring the lids to grade but were not installed at the time of the inspection. The existing tank was filled with dirt and rocks and properly abandoned. The existing cast iron pipe from the house to the tank was replaced starting approximately 21 -feet from the house with a 4% fall leading to the tank. A clean-out was installed at the point where the PVC pipe begins. The remaining cast iron pipe appeared to be in good condition. The pipe leading out from tank ties into the existing absorption area. The new pipe from the tank to the field had a 1% fall, according to the installer, and is a very short section of pipe. The OWTS was generally installed according to specifications. This observation is not a guarantee of workmanship and/or parts and materials. ALL SERVICE septic, LLC should be notified if changes are made to the OWTS in the future. Any additional OWTS construction must be according to the county regulations. LIMITS: Observations are limited to components that are visible at the time of the inspection. The installer must have documented and demonstrated knowledge of the requirements and regulations of the county in which they are working. The quality of the installation is dependent of the expertise of the installer, soil type, and weather conditions. 3 0 • Please call with questions. Sincerely, OAA (a- Oa -&A8 Carla Ostberg, MPH, REHS filter F See bedding around tank Inlet side of tank 7 <-- F 0 ct 2 k_ ri z 0 F k n H-OL5e Dec k 5 0 • j V K I N Onsite Wastewater Treatment Systems (OWTS) Use 4 r Permit Inspection Form COUNTI Pitkin County Environmental Health Department 76 Service Center Rd, Aspen, CO 81611 Phone:970-920-5070 Fax: 970-920-5374 Website: www. asoenpitkin.com/ehnr Inspection form for continued use of an existing OWTS Owner's Name: Address: Parcel Number: 0-101-1 ??J-- 1 la 7 - DID - 0 ZD Inspection Date: '7 Inspector's Name: Business Name: a 0 i fl f Phone Number Gj 7 (� _ 7QC)_ et- C:A b Email: (�Q I A _Off} L f\ n t a fxyu fkA i ((Y Y�1 Ptddn County Systems Inspector License Number; l' A copy of this inspection report will be remitted to Pitkin County Environmental Health Department by the Licensed Systems Inspector within 60 days of the inspection regardless of whether the system posses or its. QUESTIONS FOR PROPERTY OWNER PRIOR TO INSPECTION; Is the home currently occupied? YES NO If NO, how long has the home been vacant? To 2 yss o -r c> How many bedrooms are in the home? If secondary treatment is used, who is the e maintenance provider? N I RECORDS: Were system records available from Pitkin County?YES NO If YES: Permit number: -716 0--11 Date of Final Approval: q 1 % 3 It of bedrooms permitted: Was an as -built drawing available? ?YES,� NO Is the as -built drawing accurate? NO If NO: Complete a drawing of the system on lost pf thisform as accurately as possible. Any question marked FAIL will require correction before an OWTS Use permit is issued. SITE CONDITIONS: Proper grading, no evidence of erosion? PASS FAIL Improper vegetative cover? NO YES Evidence of compaction such as heavy machinery or livestock? YES Improper discharges such as straight pipes? PAsi FAIL Evidence of high ground water? NO YES Snow cover present? (2! -) AO-) YES I �v,� I� Y,IQS 6rn�if� I Page 1 It • &e l? W rEQai r5 "He a4 +1r" of TANK: Tank 1 YS%r rt ho bci �4� �v+ti ecf in ("M 25 IG pin. PUMPS/DOSING SIPHONS: Tank capacity gallons YES If YES, is the pump/dosing siphon functioning properly? PASS Tank material Does the pump/wiring/dosing siphon appear to be In good condition? PASS FAIL Is the high water alarm working, both visible and audible? PASS FAIL h of compartments Q, UNKNOWN is a secondary treatment unit present? MNYES If YES, does the unit appear to be in good working condition? YES Date of last pumping Z Z Does the owner have a current maintenance contract for the unit? YES NO UNKNOWN Maintenance Provider: Phone: Lids/risers In good condition P FAIL the home. A copy of the contract must be submitted to Pitkin County Environmental Health Department. Risers to grade YE NO Riser height 't - Riser condition/watertightness Inlet santtary T/baffle PASS FAIL PASS FAIL PASS FAIL Outlet sanitary T/baffle FAIL PASS FAIL PASS FAIL Effluent filter (if part of design) PASS FAIL N/ PASS FAIL N/A PASS FAIL N/A Condition of tank material PASS F L PASS FAIL PASS FAIL Tank was pumped for inspection YES N YES NO YES NO if YES, list the pumping company If NO, when was the last pumping Scum level (1st compartment) inches inchesqL Sludge level (1st compartment) inches inches Scum level (2nd compartment) Inches inches :PASSMidtank Sludge level (2nd compartment inches Inches Backflow (if Pumped) baffle PASS PASS FAIL FAIL N/A PASS PASS FAIL FAIL N/AWatertightness PASS PASS FAIL PA r 4 cATro clad ;> Yea I cr 1Q U-2 Ner j lJyj Q(IrS b -e le Q k ,'Yio /p waHrl� YS%r rt ho bci �4� �v+ti ecf in ("M 25 IG pin. PUMPS/DOSING SIPHONS: Is a pump or dosing siphon present? YES If YES, is the pump/dosing siphon functioning properly? PASS FAIL Does the pump/wiring/dosing siphon appear to be In good condition? PASS FAIL Is the high water alarm working, both visible and audible? PASS FAIL SECONDARY TREATMENT: YES NO UNKNOWN is a secondary treatment unit present? If YES, does the unit appear to be in good working condition? YES NO Does the owner have a current maintenance contract for the unit? YES NO UNKNOWN Maintenance Provider: Phone: If there is no maintenance contract, a contract must be in place prior to occupancy of the home. A copy of the contract must be submitted to Pitkin County Environmental Health Department. ABSORBTION AREA: Effluent surfacing? Evidence of past surfacing? Surface dampness? Excessive odors? Field location verified by observation ports or probing: Liquid in observation port? If YES, record depth: Distribution Box or ADV part of original design? If YES, is it accessible from grade? Is It level and in good condition? PASS FAIL N YES YES N YES Ports Probing ryli.�-(noY NO YES Inches YES NO > UNKNOWN YES NO PASS FAIL Page 2 7 0 • Any problems with the system 7t were not addressed in the Inspection checklist? llA0 4 tPD id1Yr[9!Y s r^� r� D i Q —��krl�nln r DV0 Ir,� � Please list any recommendations for the continued use of the system: N U,6- pg r Were any repairs done as a result of this Inspection? NO YES If YES, please describe the repairs. Al re v,k a r,e�fiWTS To the best of my knowledge and training, the Information collected In this Inspection is accurate as of IlNz 11 20 Q. Licensed Systems Inspector Signature: I AAI a n 0 ,t Ci Additional Notes: Page 3 ILA c l O'(1 PDW } 2 Pitkin County Environmental Health Department Contact Log Sheet Name: Parcel !D#: 2x{63 — 16 Z - oo _ 02o Address: 7 6oL' pate- . . Person S 'oken To.: Comments / Action tube Taken.. Initials Time Me. 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MMNt6nRlYANNNFbRq Wit p MYIN1dRixPNtIlE1Y1nXJR1'YIRIMPU[ MI14Vf1U1NOMRWOn<OInMYMM na IIImR6. oYYY101Y1 LLii 0 Well Constr Receipt: 9117294 Division: 5 Permit 11: 68961-- Water District: 38 Well Name / #: County: PITKIN Designated Basin: Management District: Case Number: W3545 WDID: 0 I Help !lest Rehesh: 4/22/201312:00:37 AM 1-1 Applicant/Owners; History Date Range Appikant/Owner Name Address CHy/Statil Url - Reyrnt M10 AND TED Po Box 9959 ASPEN, W 81611 (-7 location Information APProved Well Location Q40 Q160 Section Township Range PM Footage from Section Lines SE NW 16 9.05 85.0W Sixth 1390 N 2600 W Northing (UTM y): 4348811.5 Easting (UTM x): 337125.1 Location Accuracy: Spotted from section lines Physical Address City/State/Zip Parcel ID: 49-2643-162-00-020 Date Issued: OS/22/1973 IN Use(s): HOUSEHOLD USE ONLY Special Use: Area which may be Irrigated: Maximum annual volume of appropriation: Statute: Permit Requirements: Totalizing Flow Meter No Subdivision Name Filing Bock Lot Acres in Tract 2 Aquifer UNNAMED AQUIFERS (s): Geophysical Log Abandonment Report No No Cross Reference Permit Number Receipt Description Permit(s): Comments:Decreed as Fields Well, Div 5 Water Court casae no. W-3545. Umt use to HUD, being 1 SFO & no outside uses. Tax #R003355. Phy address: 260 Liberty Ln, Woody Creek, CO. GWS -11 needed, draw 02/27/09 C-] Con t, i /Usage Detaft Well Construction Dobe: 0728/1973 Pump Installation Data: Well Plugged: 1st Beneficial Use: 07/28/1973 Elevation Depth Perforated Casing (Top) Perforated Casing (Bott0m) Static Water Level Pump Rate 88 60 88 40 15 Lic # Name Address Phone Number Driller 655 14A1, MrE Box 619 a mCto, co 81112 970e 1310 C-7 APplkation/Pormk History Well Construction Report ReceNed 12/31/1973 First Beneficial Use 07/28/1973 Well Constructed 07/28/1973 Permit Issued 05/22/1973 Appllca0on Received 04/30/1973 I-] DnaBed Documents Do MO"t Name Date Imaged Annotated Original File 12/04/2007 No 2009 Colorado Drvis,on of Water Resources. All rights reserved. • 4-- VIRJ$6-]y COLORADO DIVISION OF WATER RESOURCES THIS FORM MUST BE SUBMITTED 101 Columbine Bldg., 1845 Sherman St. �— WITHIN 60 DAYS OF COMPLETION Denver, Colorado 80203 OF THE WORK DESCRIBED HERE- ON. TYPE OR PRINT IN BLACK WELL COMPLETION AND PUM INSTALLATION REPORT INK. PERMIT NUMBER WELLOWNER_��� A' f/- �Q}l/�� J y, of the of of Sec.__140._, AODRESSAL�' '� 9 �y l0��lf( '�//1 T. �, R. L� _(e�L, P.M. DATE COMPLETED ee!e i WELL LOG 19 L= HOLE DIAMETER From To Type and Color of Material Water Loc. 011? - TOTAL DEPTH — _ V Use additional pages necessary to complete log. __071n. from '__9 to_lad ft. _. in. from 16"— to ft. in. from to it. CASING RECORD: Plain Casing Size __Z& kind _ST from _� to Size & kind , from __ to ft. Size _ & kind from to ft. Perforated Cming Size A & kind from �//P� to 00'6h. Size ._&kind from to ft. Size & kind from __ to ft. GROUTING RECORD Material Intervals Placement Method � __r 1� GRAVEL PACK: Size Interval TEST DATA Date Tested 'T 1' �_ _ , 19" Static Water Level Prior to Test ft. Type of Test Pump Length of Test�z�-�_� Sustained Yield (Metered) �- Final Pumping Water Level O Pu Ty Po' Pui MC Da Pui Re. WE Dai Sta Ler Sus Pur Rel CONTRACTORSSTATEMENT The undersigned, being duly sworn upon oath, deposes and says that he is the contractor of the well or pump installation described hereon; that he has read the statement made hereon; knows the content thereof, and that the same is true of his own knowle e. i Signature License No. State of Colorado, County of SS Subscribed and sworn to before me this day of.. L 7g, My Commission expires: a"PirasJU W)q V I Notary Public— FORM ublic FORM TO RE MADE OUT IN QUADRUPLICATE: WHITE FORM must be an original eopV on both sides and signed. WHITE AND GREEN copies must be filed with the State Engineer. PINK COPY is for the Owner end YELLOW COPY is for the Driller. mailing address NAME IED 811ZK),9AJD STREET Sox :1/� 9 6"4 CITY � �/�/ Co6ggon 8Ila (I (State) (210) TELEPHONE NO. ?,19 — 319R LOCATION OF PROPOSED WELL County P1TK1r1 .Sq� Y. of the L, Section Two.5 , Rng. jJ& P.M, (3) WATER USE AND WELL DATA Proposed maximum pumping rate (gpm) 11 (5' PM Average annual amount of ground water to be appropriated (acre-feet): Number of acres to be irrigated: Proposed total depth (feet): 80 1750771 Aquifer ground water is to be obtained from: FRoM Owners well designation (x) HOUSEHOLD USE ONLY ( )DOMESTIC(l) ( ) LIVESTOCK (2) ( )COMMERCIAL(4) ( ) OTHER (9) (4) DRILLER no irrigation (0) I 1 INDUSTRIAL (6) 1 )IRRIGATION(6) I 1 MUNICIPAL (8) Name0,OI1I,v6 1)R/hl.IN& 0-0 Street nn City l� a R 00" e D 14kE 8 Ra t at•) t Io) Telephone No. 963-98( Lie. No. FOR OFFICE USE ONLY: DO NOT WRITE IN THIS COLUMN Receipt No. �00Q& / Basin Dist. CONDITIONS OF APPROVAL This well shall be used in such a way as to cause no material injury to existing water rights. The issuance of the permit does not assure the applicant 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. fix be usM4for Irrigation. The return flofor w troms(hekusemll�dtypin must to be returned to the same stream system in which the well is located. thiss wen 8F -.b APPLICATION APPROVED PERMIT NUMBER 68961 DATE ISSUED 114 8 2 1973 EXPIRATION DATE MAY 22 1975 • 9=000 ra 4 R) BY A I.D. -5 3 8 COUNTY_ 4� • • i' RECEIVM Wpu-!5�72 COLORADO DIVISION OF WATER RESOURCES 101 Columbine Bldg., 1845 Sherman St., Denver, Colorado 80203 AN PERMIT APPLICATION FORM Application must *477 be complete whore ( A PERMIT TO USE GROUND WATER���ei@ applicable. Type or A PERMIT TO CONSTRUCT A WELL print in BLACK FOR: A PERMIT TO INSTALL A PUMP INK. No overstrikes or erasures unless 1 ) REPLACEMENT FOR NO. initialed. ( IOTHER mailing address NAME IED 811ZK),9AJD STREET Sox :1/� 9 6"4 CITY � �/�/ Co6ggon 8Ila (I (State) (210) TELEPHONE NO. ?,19 — 319R LOCATION OF PROPOSED WELL County P1TK1r1 .Sq� Y. of the L, Section Two.5 , Rng. jJ& P.M, (3) WATER USE AND WELL DATA Proposed maximum pumping rate (gpm) 11 (5' PM Average annual amount of ground water to be appropriated (acre-feet): Number of acres to be irrigated: Proposed total depth (feet): 80 1750771 Aquifer ground water is to be obtained from: FRoM Owners well designation (x) HOUSEHOLD USE ONLY ( )DOMESTIC(l) ( ) LIVESTOCK (2) ( )COMMERCIAL(4) ( ) OTHER (9) (4) DRILLER no irrigation (0) I 1 INDUSTRIAL (6) 1 )IRRIGATION(6) I 1 MUNICIPAL (8) Name0,OI1I,v6 1)R/hl.IN& 0-0 Street nn City l� a R 00" e D 14kE 8 Ra t at•) t Io) Telephone No. 963-98( Lie. No. FOR OFFICE USE ONLY: DO NOT WRITE IN THIS COLUMN Receipt No. �00Q& / Basin Dist. CONDITIONS OF APPROVAL This well shall be used in such a way as to cause no material injury to existing water rights. The issuance of the permit does not assure the applicant 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. fix be usM4for Irrigation. The return flofor w troms(hekusemll�dtypin must to be returned to the same stream system in which the well is located. thiss wen 8F -.b APPLICATION APPROVED PERMIT NUMBER 68961 DATE ISSUED 114 8 2 1973 EXPIRATION DATE MAY 22 1975 • 9=000 ra 4 R) BY A I.D. -5 3 8 COUNTY_ 4� • 5)THE LOCATION OF THE PROPOSED WELL and the area on whicfi the water will be used must be indicated on the diagram below. Use the CENTER SECTION (1 section, 640 acres) for the well location. + — ...r .— -+ — + — -1--- -i- — --f - — .'.). — 4- 4-1 4-1 MILE, 5280 FEET — + 1I + — - _ NORTH SECTION LINE I �NORTHJ 1- z I z U w I H I + — F I I I I 1 r -+-+I j + y� aVV Irl JCti 11U1Y L11Yt i 1 The scale of the diagram is 2 inches = 1 mile Each small square represents 40 acres. 0 (6) THE WELL MUST BE LOCATED BELOW by distances from section lines. A'90 ft. from sec. line 7'&W vi, -1fIT,f "Muth) worn r.� _sWft. from E=S -1 W. line LOT BLOCK FILING s SUBDIVISION (7) TRACT ON WHICH WELL WILL BE LOCATED No. of acres a . Will this be the only well on this tract? 0)PROPOSED CASING PROGRAM Plain Casing -7 in. in. from O ft. to _O ft. in. from ft. to ft. Perforated casing ___7__ in. from _&9 ft, to 53 h. in. from ft. to ft. I (g) FOR REPLACEMENT WELLS 9: f and direction from old well and plans forplugging — j it: WATER EQUIVALENTS TABLE (Rounded Figures) Ana' edoot cover[ 1 sae of tared 1 foot deep 1 cubic foot per second (cfs) ... 449 gallons per minute (gpm) A family of 5 will require approximately 1 acre-foot of water per year. I xre-foot ... 43,560 cubic feet ... 325,900 gallons. 1.000 gpm w+moed confinuomly for one day produces 4.42 mvm feet. (10) LAND ON WHICH GROUND WATER WILL BE USED Owner(s): _ f�D dl 30617#4 A— L+ ('3lRK�a�� of the use of ground water: (12) OTHER WATER RIUM used on this land, including wells. Type or right Used for (purpose) /V0 A(Z-=' No. of acres:aHG��S Description of land on which used (13) THE APPLICANT(S) STATE(S) THAT THE INFORMATION SET FORTH HEREON IS TRUE TQ jHE.0ES7�F�iIS KNQIQ)ILEDGE. n /f Use additional sheets of paper if more space is required.