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wrt~.s lz COLORADO DIVISION OF WATER RESOURCES ~ //^/ <br />101 Columbine Bldg., 1845 Sherman St., Denrer, Colorado 80203 {-~ <br />4pplica•icn must <br />.x: complete where <br />applicable. Type or <br />riot in BLACK <br />N K. No overstrikes <br />or erasures unless <br />initialed. <br />PERMIT APPLICATION FORM <br />1 ) A PERMIT TO USE GROUND WATER <br />U(I A PERMIT TO CONSTRUCT A WELL <br />FOR: I~QA PERMIT TO INSTALL A PUMP <br />( )REPLACEMENT FOR N0. <br />1 1 OTHER <br />w~'1 <br />1 r S L. <br />r~l.it~~~l1 <br />. TY VaWip~.~ <br />I1) APYLICAN7 • mailing atldress <br />NAME /~~£f/ ~frt.,Py ~ V~~N! <br />STREET 'rTpN~C lvt9LC PL.y~`~ <br />CITY G/•Cd T+ "~ CaL x/09/ <br />IState) (Z[p) <br />TELEPHONE NO. ~`L - ~~~ <br />12) LOCATION OF PROPOSED WELL <br />County _ <br />~• ~ '/. of the N• ~/ %., Section <br />3a <br /> <br />'3) WATER USE AND WELL DATA <br />,oposed maximum pumping rate (gpm) ~`r <br />Average annual amount of ground water <br />to be appropriated (acre-feet): <br />Number of acres to be irrigated: N ~ /V /t <br /> <br />Proposed total depth (feet) <br />7D , <br />Aquifer ground wafer is to be obtained from: <br />r / <br />Owner's well designation ~!//~~(. Ne <br />GROUND WATER TO BE USED FOR: <br />( HOUSEHOLD USE ONLY <br />( 1 DOMESTIC I11 <br />( 1 LIVESTOCK (2) <br />1 1 COMMERCIAL (4) <br />no irrigation 101 <br />( 1 INDUSTRIAL 15) <br />( )IRRIGATION 161 <br />( )MUNICIPAL (el <br />I )OTHER 191 <br />14) DRILLER <br />L i C ti.t, a ,{7 <br />ame <br />~eet <br />Ci[y <br />(State) (ZIP) <br />Telephone No. Lic. No. <br />L ~ Ate; .-r ,.,r <br />FOR OFFICE USE ONLY: DO NOT WRITE IN THIS COLUMN <br />Receipt No. ~~l x,7-,7 / <br />Basin <br />Dist. <br />CONDITIONS OF APPROVAL <br />This well shall be used in such a way as to cause <br />no material injury to existing water rights. The <br />issuance of the permit does not assure the applicant <br />that no injury will occur to another vested water <br />right or preclude another owner of a vested water <br />right from seeking relief in a civil court action. <br />bye u~d }orrirtlgatipnla Thepreltum flowefromstheeusa alethisgnwe0nmust a <br />~~~ k the same stream system In which the well is IPCeted. <br />BED ~~~~>/~~- <br />APPLICATION APPROVED <br />PERMIT NUMBER 6 V S 4'7 <br />DATE ISSUED DEC 1 ~ 197'2 <br />EXPIRATION DATE DEC 13 1974 <br />(ST NG ER) <br />BY <br />I.D. COUNTY <br />