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FORM NO. <br />13W8•11 <br />am <br />STATE OF COLORADO <br />. OFFICE OF THE STATE ENGINEER <br />8111 Centennial Mg., 1313 Shannon St.. Denver, Colorado 10203 <br />: (303) 11564551 <br />For Office Use only <br />RECEIVED <br />0 41997 <br />AUG <br />WERATER ESOURCES <br />STATENGINELR <br />COLO, <br />• <br />?NOR TO COMPLETING FORM, SEE DISTRUCTIONS ON REVERSE six <br />CHANGE IN OWNERSHIP/ADDRESS./ LOCATION <br />IP/Ell PEr, LIVESTOCK TANK OR EROSION CONTROL DAM <br />1, <br />MUMMER <br />NAME(S) MAYER FAMILY FARMS,, LLC <br />Mailing Address 97.04...1fIGHWAY...£6 <br />City, st zip .. ........ ....PLATTEVILLE, CO.... .... B005.1 <br />Phone L970.. ) -785-2371 <br />2. <br />THIS CHANGE IS FOR ONE OF THE FOLLOWING: <br />r <br />0 <br />WELL PERMIT NUMBER R- I 5750 -RF <br />LIVESTOCK WATER TANK NUMBER„„...., „ .„ ...... .... ...... ..., ............ ,... <br />EROSION CONTROL DAM NUMBER <br />S. <br />WELL LOCATION: COUNTY wELD. OWNER'S WELL DESIGNATION IRRIGATION SPL. <br />(Andra* <br />NW 1/4 os the NE 1/4, Sec, 33 wp, 3 <br />Distances from Section Unes ... ..... 1.4.0 Ft. from <br />12 <br />Ii <br />N. or <br />N. or 08. <br />(CRY) (glide) <br />S., Range, 6.7 El E. or El w. „,6th. <br />Line, 2300 Ft from [ii E. or <br />itaP) <br />, P.M. <br />W. Line. <br />Subdivision Lot Block Filing (Unit) <br />4. <br />LIVESTOCK TANK OR EROSION CONTROL DAM LOCATION: COUNTY <br />1/4,• Sec. Twp, <br />II <br />N. or 08., Range <br />or 0 W. P.M. <br />5. <br />The <br />The <br />ri <br />— <br />above fisted owner(s) say(s) that he May) awn the structure described herein. <br />existing record is being amended for the following reason(s): <br />1-1 <br />Change in name of owner. 0 Change In mailing address. LI Correction of location. <br />S. <br />I (we) have read the statements made herein, know the contents thereof, and state that troy are true <br />to my (our) knowledge. <br />(Pursuant to Section 244-104 (13)(a) C.R.S., the making of false statements herein constitutes perjury in <br />the second degree and is punishable as a class 1 misdemeanor]. <br />Narnefritle (New Owner) Please type or print <br />MAYER FAMILY FARMS, LLC <br />OROTHY . Y ; A'I.1- <br />SiM,11(Nel..-6--• <br />rea......r.I, <br />,ALI ).A1 4 <br />/ <br />Date <br />FOR OFFICE U E ONL <br />ACCEPTED As A cHANGE x owmutsinp <br />AND/OR MAILING ADDRESS. <br />• / <br />di A. I,,s•"• , SEP I 8 1997 . . <br />Dde • <br />Court Case No. it.) -//41‘ Div. / Coe:2J WD X Basin MD One <br />