1.0 Application[Icon]

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APPLICATION
gccbl Us pcnlt
RECEI\rED
GARFTELD CO^TINIY PIJNI\MYG DEPARTMENT
:Otnigttt
Stro.t, Sufr"a{x}
Sprhg CO tl60l
. Glenwood
'l'elopbonc:
97 0-94 -OZl2
Facsirnite:
S
,i;;'
g 7 O-3 84.3
47 O
sEP 2
CTARFIELD
5
2002
COUNry
BUIIDING & PLANNII{G
Base Fec: $,t00.00
Submittal Date:
Applicurt:
Address
ofApplicaor
'elephone:
Conditional Use Boing Rcqucstod:
Zone District:
Sizc of
propony'
b:* . LtS oreneg
Applicatiou Rcqulreoents: Ttese items must bo
submitted with tlc aoorication
l
')
Plans-and specifications.for thc
qroposed use including the bours of operation, the amount of
vebicles accessing thc site o, duily,
yalof mlonuybasis, and the sizc ofaay cxisting or
" utiitdy1uy
proposcd struchrres thrtwitl bc
incoqjunctio.*-t h'tr
this
infonnation in nanutive forrn and bo spccific.
Uyou will bc using waler or will bc tiating rvastcwater in
conjructim with the prcposed usc,
plcasc detail sc amount of water ttret would
bo usod and the tlpc of wa*u,"tor'uoL*e If you
will bo utilirinS
ortu
wcll pcrmit and any other
3c.ll yaar, please attach n
legal wator $upply inforrnation, inctuding "opy
or an apprlvcd water
augmentation plan.
"
A map ttrawn io scale portaying your propsrty, all stmctures
on dre property, and the county or
sato roadways within oue (i) miie of yo,r pripcrty. you
If
are proposing a new or expanded
acccss otrto I county.*
ro{way, submit s ari**"y
fip*.i;;#zubmit
2')
.rrr"**
*iio"lo1aiii ilo*.,
3')
or hiffi,d.;p;;'
tlo of yourproperry,
4') Avicidtymap, showingslope
forwhicl aU.s-.G.sl t:24,0-06;;iJqruarangte
nap will sufEcc.
5') A copy of the appropriatc portion of a Garfield_cq*_ty
Assessor's -\Iap showing all public and
privatc landowuors adjacent to your groperty.
Include a list of all propert/ owne- and 6cir
addresscs.
6') attacu
e coPy
of the deed and a legnl deocriptioo of thc property. If you are
acdag as aD ag'nr for
rnusr attac-h an acknowredgem.it dootr" p-p.*v o*r"-rr",
you
,.y
* f,ffirililfr.rou
7') You
must submit an impact statcmcnt consisteni wi0r
fre requirernents of$ctrJrEri5.5:03;
.pgBgFJbg nlinr'3. (oa industrial
bpo use applicatiorr r..ti'or, s.o3.o7 aad 5.03.08 will bc
nccessrryto address).
Thc considerution of &is
f;lPosea spocial uso will requirc at Ieast oue (l) public hearing for which
-
public noticc must be
ffus ptanning ognutni.ni*rti ;1iiy"" inisn,atiou.on-."^iog
tui,
hearing(s), appooxitni"tvis &vl prlor to ttircr,lo.roo
g. iJu *iu
required to norifi, by
certifiodretum rcceipt oail to alt owners of record
t"o_E
es shown in-tho Assessor,s Office of lots within
200,
of the subjoct lot aod to all owncrs of mineraltterur
in the subject propsrry aac publish tbc notice
provided by tbo Plauning Dopartnent, in
a ncwspaper of generel cigrlation Borrr these notices
rnust bc
mailcd/published at leasi:0 6ut not ,noru ,n*
60.L.", jrlo.," ,t" p"uu. hearing. Tho appticant shall
th-c cost of mailing and publication and proor
p[uu*tron rnusr be submitted at ttre
lcar
trmo of public hcaring.
"Tlq{.
n*t
oiniitirita
The informstion containcd
Applicout
**'Pleare,
\
withir
application is complcte snd conect, to the bcst of ury
knowlcdge:
fi::,H
Narrative of Plans for Home
We were gifted approx. 28 acres of land that already has one single family
motJular home on
it.
We plan to place a second modular home on the property with its
own separate well, septic systenr, and utilities. This home will be placed on a foundation.
The home will have 3 bedrooms and 2 bathrooms. It is 1,869 sq.
ft.
We plan to designate
this the primary home on the property. The other home, which is less than 1500 sq. ft.
will be designated
as the secondary home and is already
are planning to set up
will
occupied. Since the home we
be our primary residence, the hours of operation cannot
h
accurately stated. The amount of vehicle access will be limited to no more than 3
vehicles daily. We do plan to use and set up the plan provided to us by the county
building office for our septic systenr, which will consist of a 1,250-gallon septic tank with
an adequate leech
field. As for our well we plan to drill at least 76 ft. if not further. The
well will be hooked up to a filtration and water conditioning systern We have provided a
copy of our well permit application. The home will have its own electrical meter that
will be set up by the electrical company in our area. We have provided
a copy
of our
electrical permit as well. We also plan to set up an appropriate propane tank on the
property to provide gas to the home for energy purposes.
Exnlanation of Plans for Section 5.03
1.
As we explained above we plan to drill our own well to provide water to the
home, set up the septic system suggested by the county building office, and set up
utilities appropriate for our homes energy needs.
2.
We are not aware of any improvements needed to access the property but we do
plan to pave the driveways on the property.
3.
We do plan to install a fence along the adjacent property line. We do intend to
include some sort of landscaping to provide privacy to both sides of the property
Iine. We do plan to set up a streetlight outside along the driveway as well for
safety purposes.
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SEFI0-02
T-287
09:17
P
00r/001
F-443
STATE ELECTRICAL BOARD
ELECTRICAL PERMIT NUMBER: 425832
JOSEPH WILLEY
P.O. BOX 1084
RIFLE, CO 81650
Daytime Phone:
970-625-+1 31
Power Supplier:
PUBLIC SERVICE. RIFLE
Owner Name:
JOSEPH VV]LLEY & BRANDY
Job Addrees:
30414HWY6&24
Fax:
970-625-9044
RIFLE
GARFIELD
DIRECTIONS TO JOB SITE
I NSTALI-ATION DESCRI PTION
Modular SeMce
MODULAR HOME
INSPECTOR: Owens- For lnspection Call: 970/62&6086
Squarc Footaga:
0
Cost of Elcot. Work: $
1,950
S
Fee
45.00
Paid by: Check # 1789
COLORADO STATE ELECTRICAL BOARD
DEPARTMENT OF REGULATORY AGENCI ES
425832
1560 -ogan Street, Sun6 550, Danv6r, Coloredo 80203-1941
Phon6: (303) 894.2300
425832
@oFWATER
Form GWS-44 (1/2001)
REI'RCES
DEPARTIIIENT OF NATURAL RESOURCES
1313 SHERMAN ST., RM 818, DENVER, CO 80203
phone
- info: (303) 866-3567 main: (303)
866-3589 htttr//w*
866-3581
fax: (3O31
jrJL 1 5
RESIDENTIAL Noh: Also t,3c rhls form to applv ror llvestock wetorins
Water Well Permit APPlication
'iiiUl"ii'i.Hi"
Revlew lnstrucllons on revcrlo rldc prlor to completlng form'
The form must b€ completed ln black ink.
1. Aoolicant lnlormetion
N*m
_6_.__V:_e_g_f_W-q!!(check.9g:licable.-boxes)
See rnstructions ro determine use(s) lor which you may quallly
[l A. Oroinary F,ousehold use tn one single'family dwelling
ot 6PPlicrnt
&
Ig$P-1
--!reN.v-"!.i
rd6,ots
l-i-e-v--
(no oulslcle us€)
M6iling
525 E. 1 2th St.
B, Ordinary household use in
D
-l u6 -_-_Tg,:tsEo
filiG--
lttvru' t6?5-4131
2. Tvpe Of Applicarion (check applicable boxes)
[Use existing well
E Constrr.r n€w well
I
D
increase use
Reapplication (expired permit)
Cnangc
3. Hefer To (if aPPlicablgl
Well porrnir
,
Oggqnatcd B8sin Oolslmrslias
I W!ta,
i wrll
I
E
Home gardenilawn irrigalon, nol to sxc€od one scte:
E sq. tr, E acte
arca iriigated
El
Domeslic snimal watering
wettp3g_iggP9ggg1
_l
rlro
Mlrrmum
pumprno
flother,
Courl ca3e
ncmc or
f
,
otiiooOn
4. Location Of Proposed Well
CauntY
I--r/4orth€--1/4
Garf igld
-ijiirmie ot Mll
.,-
_.*-.. )-....
_
-.-..
-_--
iB,
lte
l,om 3eclron lrnss (*crion hncs
0l
D
Effi I "H,tittp:r.-
!
typrcallv nol proportv lrne6)
qq rr.rromElNES
For rapltcamnl well'
qpm
lE
,66t
enrual lmounl (o ba withdrlwn
I
iI
acro-leet
Aquiltr
i
tap
ol
name
YEs
kJ
NO
supplier:
9, Type Of Sewage SYstem
I
-
- (non-commerciall
8. Water SuPPlier
lr thl", pr*"| *,thh boundaries of a water eervico area? U
,
lf yes, provide
s.ilr-----"fg;ilfi,e
dwellings:
C. lrvestock walering (on farm,rranch/range/pasturel
!
r-rr
I to 3 single-farnily
Number ol dwellings:
l___t_
D Replace exrsring well
0 Change source (a<iuilar)
2AA2
Ftrrcm!EBw
Cenrral system: District name:
Vault: Locotion sewage to be hauled to:
D Other (attach copy ol engineering design and report)
f O propo""d Well Drillor License #(og!gr,gll-4&,.
I t. sigt"t.lte_g! Applicantls-L qlqbgtkoq-Agglt
onlY
,6et
Sepric tanx / absorption leach lield
direction
[,efr lcorton .dd.r.. lil .gpirc.bbi
f i," rn"fing ol lalee stat€ments herein constitutes perjury in the second=degree, which is punishabl€ as a class I misdemeanor pursu6nt t0
C.R.S. 24-4-104 (13)(a). I hav€ read the statemonts herein, know th€
contents lherecf 8nd state rhat lhey are lrue tC !nyl!qti,!€dg9'
Optionrl: GPS well location inlotmation in UTM lormat
Reouired scltinos tor GPS unils aro as lollows:
Format murt br UTM
i
3
Nonhino
i
Marors
o.rum mulr b. NAD27 (CONIJS'
E 66ting
Unrt rutl ba sat lo lruc nonh
wers pornrs avet.q,al? D vgs E no
5. Parcel On Which Well Will Be Located
zom mst b.l
I
lr'nrts mu6l be
I
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idv----S=-9!ltse-9:l
nama
:
usus mr9
A.You mu6t check and complete ono of the following:
tr
t]
E
tr
subdivlsion: Name
Lot-
'
Block-
-z
:
*",''-----
( 7. fteA
Filing/Unit
Counly exemption lattach copy ol county approval & survey):
Lot 'l
r.
i
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Parcel less than 35 acres, not in a subdivision, attach a deed with
metes and bounds description recorded prior to June 1 , 1 972
cooy ol rh! dlsd or turvGYl:
--
Squaro
40 acre parccl
E. stttr
P.r6.l
orilY wsulmtrx.
lo, lootlooll:
pr
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involce il 495e85
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Cashier ID: 0l
r
69,00
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aa deecribod in
ltem 4
p.rc.l, [J vrs !
No lil no
Check Furchase- il1742
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, Q. lrl Ya lha own€, ot thrt pltcol?
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Addresses of Adiacent Landowners
I . Robert &, Elaine Coloroso
P.O. Box 33574
Northglenn, CO 802 33-057 4
2. Verna Mullet
14459 County Rd. l8 %
Ft. Lupton, CO 80621
3. Donald & Angela Parkison
P.O. Box 790
Glenwood Spritrgs, CO 81602
.ilffiil lllll llllll lllll llll lllllll llllll lllll llll llll
608315 OE/O5/2hO2 O4229? 81375 P497 il RLSDORF
t oe 2 R 10.00 O O.00 GRRFIELD C0UNTY C0
L{q7
Rccordcr
QU ITCLAIM DEED
TIIIS DEED,
between
of
made
verna
this d
day
July,2002
of
L. Mullett
County
the
of Weld
and State
or Colorado
, grantor, and
Joseph O. Willey and Brandy WilleY
whose legal address
is 349 South 9th Street #6, Rifle, CO
81
650
ll
County
of the
of GartieH
WITNESS, thar the Sranror, for and in consitleration of the sum
, grantee
and Srate ot Colorado
or ten dotlars and other good and valuable consideration
presen6
DOLLARS, the receipt an6 sufficiency of which is hcreby acknowletJged, has remised, released, sold and QUITCT-AIN'IED, and by these
joint
does remise, releasc, sell and QUITCI-A,IM unto the glantees, their heirs, successors and assigrs forever, not in tenancy in common but ln
tenancy, all tlre riglrt, titlc, intcrest, clairn anrl rlcmand which the grantor has in and to thc rcal pr()perty, toS,cthcr with improvemcnts, if any,
and Statc of Colorado,
Garfield
County
situate, lying and being in tlte
of
described as follorvs:
See Exhibit "A" Attached hereto and Made a Part Hereof
also known by street and nunrber as;
assessor's schedule or parcel number:
TO IIAVE AND TO IIOLD the
same, together
with all and singular the appurt€nances and privileges thereunto belonging or in any\ise
thereunto appcrtaining, and all the estate, right, title, interest and clairn whatsoever of the grantor, either in law or equiry, to tire only proper use,
benefit and behoof of the granteest their heirs and assigas forever.
The singular nunrbcr shall inclutle the plural, the plural the singular, and the usc of any gctttlct sltall be applicablc to all gendcrs.
IN WITNESS WHEREOF, the grantor has cxecuted this deed on the date set forth above.
STATE OF COLORADO
)
)ss
County
of Weld
)
day
The foregoing instrument was acknowlcdged beforc me this
q
July, 2002
of
Verna L.
Witness my hand and official seal.
Itlyconrrnissioncxpircs: I
, -^-l
n
f',_;
.SL-#6-Rifle,CO 816s0 Nurr
No. 962. Rcv.
{-9{.
QUITCI-Ali\t DEED (lo Joint Tcnants)
I- / /-t' - O l;
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an<l
Addrcss of
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.{h,
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81375
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D 0.00 cRRFTELD couNTY c0
Exhibit "A"
Township 6 South. Range 92 West of the 6il'P.M.
Section 7: A tract in Lots I and 2, South of the South right-of-way of the Denver and Rio
Grande Western Railroad and North of the following described line:
Beginning at a point on the East line of Section 7 whence the Section Corner common to
Sections 7, 8, 17 and 18 bears South 00o36'00" East 4,555.27 feet; thence South
69"36'00" West 265.53 feet; thence South 72"22'00" West 792.00 fbet; thence North
78o16'00" West 595.00 feet; thence North 84o49'00" West 462.00 f'eet; thence South
64o08'00" West 363 00 feet; thence South 49o08'06" West 325.00 feet to the West line
of Lot 2, Except the West 300.00 feet of even width of Lot 2.
No.
GARFIEIDU'UNTY
B I)ILDINA, SANITA
TION ad PIANNTT.IG DE?ARTMENT
l(D tth Srrcct Suitc 3fiI
Glcowood Snri.A",
(3O3)
golorl*
tra0,
9,t5{2r2
Job
Naturt
ot-m
Ofen
Contractor-_
Olmgr
Arouor of krmit
g
141
ffi
e. Wiffey
.00
Investlgatlon
pn," January 18 ,
Fee
|
72.00
S. Archuleta
l
I
E
L9g4
5007
0ARI|i.It,l) 00uNI'y
AI'TI],ICA]:ION FOIT BU.ILD:ING rliIUI.Tl]
I'UIOIt't'
Assessorre parcel
TO
pLease
#
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IJE
llrjnf or
trx,u,fr
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BDTVTS
FJ
TLING
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x
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LOl'. l!
II
scLbfri|-i-
LEGAL (sEC
BLOCK
II
/'t,wN /ttNG )
tl
LING
E
i,o'f I,LAli
No'r'E: sltow easenenLs, pr"i"*,J lir*-El6llorr.
a17 rsl:lter st:t.rrct:ur:es , specify nortlt, and streei
,ra,rk}. I'or oejrl -s/r,:ped 7ots, or if space is
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PDRMI,T'
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.l7lyr?any sEttER
()N SII'E SDTIAGE
(.)'1'tIER
CLDAIIANCE
DTSPOSAL PERM.I'1'
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,
f herebq acknawl<:dge thai "t lrava read tltis
al;l>licaLiorr atrd tlte abc>ve i.s cor-rect and f
a9ree to conrplv w.itl, a.l j coutrty ordlltance.s
.rrrdAtate Larn's r.-egulf, tj
il.clinq constructir.
Zi)
sI
I'ALUAl'ION
lrfn/rrf'I' IIEII
l'oT'AL E',EE $
Y
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DAI'TI PERMIT TSSUEI)
qllR 0ti'rrcE usn otrr,v
FL0OD IIAZAR,I
PI*iffiTTE€,( I;'ED
oo scilooL .It4PncT
ttltE
---
ZONIIIG D-rS7'IlTCT
CIiRTIT'TL:D BLDG ELEVAI'ION
SPEC.l'At COND{I'rONS
ta10Bt'EI"1S
I'YPE OTI OCCUPANCT
'ryPE OIt c?ilsI.RUCI?off
7.'tt I,El?M7'1'
ADDIl'1'ONAT, ] NT'O'II{fl TJOT' NEEDED
cclt't,rttil:D
lJy CQLORADO
OR ENGl'NEE|1
APFROVED:
//DA'1,'E
AI'PIIOVED:
NN TN(;
118 G
r
s,1' E RE
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oi
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November 10, 1993
Don:
1.
-i
I tentatively set up an inspection /investigation of this property for you on
Monday the 1Sth,
It is a shed used for storage that was built without a permit. Michael sent
them a letter and they came in and filled out the permit.
Mr, Bernie Willey is going to contact his father in California to discuss ttris
with him. They may be intetested in calling this an agricultural building.
However, Mark said that he did not think that this property was being used
for an agricultural use.
When you look at the building, would you please look at the use of the
property and give me an opinion on whether or not it is agricultural.
I asked Mr. Willey to make out a check for the $144.00 fees on the permit.
He may or may not have this depending on what his father has to say about
it.
Thanks,
"rrdl
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t
Narrative in Regards to the Existing Residence
This house is a modular home with the axles and wheels still
in place underneath and skirting around the bottom. The house was
actually remove from a site near Rifle Falls and transported to the
site where is now. Olen and Opal Willey purchased the property in
1967 . The home and septic systems have been in original form
since the initial installation in 1967 . Since building and septic
permits were not issued until 1973, there is no documentation
regarding the home or septic installation. To my knowledge there
have never been any major improvements, additions, or
maintenance to the home or septic system. Further more, there are
no plans to make any changes to the home. In regards to the water
that supplies the home, the original water source was an open well
that was dug by hand and water was also hauled to the home from
an outside source. Some years later a well was drilled and I have
provided a copy of that well permit. I have also provided a copy of
the floor plan for this home. ln regards to the vehicle traffic on the
property, there will be an average of 6 trips on and off the premises
a day.
RECETVEI}
Joseph Willey /flrrandy Willey
,% G.4'C&K
OCT
2I
'daat
CIARFIELD COUNTY
& PLANT{ING
alronrc
Property Owners
r''{,iLil
ctu'
henu
(&,
t. > - t'[VV
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5\?f
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n:rtw,6vc( Ahy#''
O.o*oDo
WRJ.5.Rcv.76
DrvrsroN oF wAren
netces
818 Centennial Bldg.. 1313 Sherman St., Denver. Colorado g0203
must
be complete where
-/ peautr TO usE cRouND WATER
(a,e
('tyPERMlr
"rA PERMTT
applicable. Type or
print in B LACK
I
N
or
in
f^*2\
;'l' ?.Y 1
PERMIT APPLICATION FORM
Applrcation
FOR: (
K. No overstri kes
erasures unless
itialed.
/.\;
'.
f:i:
,. o-
To coNSTRUCT A WELL
TO TNSTALL A pUMp
\c.)
} REPLACEMENT FOR NO
\.'1.
} OTHER
(1) APPLICANT . mailing address
-^i
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FOR OFFICE USE ONLY: DO NOT WRITE IN THIS COLUMN
.,
rrrarvrg
Recerpt No
- 5,1q\q \\'..\.,1 [d ]rt
sTREET
crrv ?rQ\qTELEPHoNE
No.
?7o 'f-
Basrn
9r:
-,S.
Cornty
C,.c.
"
3.f,) i
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 notlssure 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.
$.,\&
qfiry{Ae.b,A,,a^s.?2+<W, 6
G
p.u
7- ?5
Proposed maximum pumping rate (gpm)
to be appropriated
lz
3
water
(acre-feur't,
of ground
/ 52
2 r77
>f RrQ
o f E.t/
5.t/t.
/ 3o7 t/.t/
(1
- -?r)2qon:
Proposed total depth (feet):
Aquifer ground water is to be obtained from:
.',-. c-
07/ oa a?/
Sai/-'-.
no irrigation
r
466o f,;
F-
/3oc
)-
LIVESTOCK (2}
) oTHER
(01
Ft
O-
(9)_
DEIAIL THE
USE
-feur<
lzt:r
,,ff,fllyHffl[,
() INOUSTRIAL (5)
( )tRRtcATtON (6)
( ) MUNtCtPAL (8)
COMMEBCIAL (4)
c_
1(6 €/- j{s27
Owner's wel I designation
({t HousexoLo usE oNLy
P?.?rsffi€t/-lerrqll
/.,^
/3aa :
o.sar'E4_r.
zuo/)
Number of acres to be irrigated:
4 //a,2,'u-- G /a-o /z ri
(r( (zu-tZ
"',f "' g
/n.au(
(3) WATER USE AND WELL DATA
Average annual amount
Drst.
B(.hi.r,(-.
(2) LOCATION OF PROPOSED WELL
I
!
(
'
- \(?c,ir;
-
WATER COURT CASE NO.
jl
'on
'|)'
APPLICATION APPROVED
ON BACK IN (11)
(4) DRILLER
PERMIT NUMBER
*,^" ,lfirn 5 fun,-,*, o^
DATE ISSUEO
EXPIRATION DATE
Street
City
Telephone No.
tic.No.7
7
8Y
t.o.-.r
COUNTY
23
3F
,a.
,(]
(6) IH
+-
-+-|
-l-
-_
!--
-l-
l<.-_ r M|LE, s28o FEET
Lr,
r-r+r-1-
I
f+
n^
NORTH SECT
-l -
I
-+-
lI
t
atS 6arr.
_1_
/3oo
+
-'
I
-l-
- + +_
ft.from
LOT--BLOCK
+
+
_4ffil(_sec
,€r/sf
(€art or wait)
-]_- -t
I
i
r
(7)
r_ocAIEA
No.of
I 7
urro,
iJt.rs
e. i3
--F-
I
-+-
I
f-+
+
+
I
I
-+ lt
i1
I
++
the only well
Owner:
Will this
on this tyacr?
(B) PROPOSED
I
I
Irr
T++++
+
rtl
l-+ -l_-+-+--F-r-
sec. line
.-FtL|NG
I
I
rine
SUBDIVISION
I
+
rrom
be
7Z J
CASING PROGRAM
Plain Casing
from + 1
,ro (?
42 in. tro^ 41
o t.ro 6o
Ao
$o
Perforated casing
4/:,
42
A.J
loo
$o
6,
in.
tr.
ft.
,r.
I
+
I
I
-It.rt
in.
from
ft.
to--
(9) F98 REPLICEMENT WELLS
and direction from otd
+
it:
ft.
stuu
weilai7ffisior
,r/4
The scale of the diagram is 2 inches
= I mile
tach small square represents 40 acres.
Jirtun..
ptulging
WATER EOUTVALENTS TABLE (Rounded
Figuresl
covers I acre of land I foor deep
l:I cuorc
.t-:t-";b9t
toot per second (cfs)
A famrly of
::t-.j::
S
...449gailons pgr minute (gpm)
wilt require aop.roxi-"tity I *i"_rooi
oi *"(er
per year.
-
I
:.._11f 99
1,00o
gpm oump€d
reer .
.'izs.soo
;ffi ;,
:yu;c
"o",i.roriiv ;;; ;;;;#;o',jt"". o.o,
acre.reer
(10)
Owner(s)
{z1-
:
f , h-..'//e
No. of acres:
t 2"f .96
Legal description:
(11)
domestic wells must indicate type of disposal
system to be used.
42
uSe
(
'aSa /
/,
n
/ -'c
au lS-'/c-
<<c4-
12)
Type
or rtghl
Used for
(purpose)
Descriptiorr of land on whrch used
(13) THE APPLICANT(S) srATE(s)
THAT THE tNloEMA-TtoN SET FORTH HEREON
IS
TRUE
^TO THE BEST OF HIS KNOWLEDGE.
flGNATURE OF APPLICANT(S)
Use additional
iheeti of paper if mors
rpace
ir
required.
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