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ATTACHMENT A <br /> WAJ•5� 76 COLORADO DIVISION OF WATER RESOURCES CEiVED <br /> 819 Centennial Bldg., 1313 Sherman St.,Denver,Colorado 80203 <br /> AUG 10 1999 <br /> PERMIT APPLICATION FORM <br /> Application must KAM RMRGES <br /> be complete where b �1 E (x)A PERMIT TO USE GROUND WATER _ ,., �..e fk <br /> applicable. Type orf� L { )A PERMIT TO CONSTRUCT A WELL t �, " <br /> 30 <br /> print in BLACK OR: (X )A PERMIT TO INSTALL A PUMP �JLA)�t ')" <br /> 1K.Nooverstrikes AUIG 10�.���� R;TUiD P0960 <br /> or arowres union ( ) REPLACEMENT FOR NO. W2472 60.00 <br /> initialed Was R om' ( )OTHER NMI P-01U3 <br /> g „FNti1HE1R WATER COURT CASE NO. S:T 130.0fli <br /> 0f - <br /> (1) APPLICANT-mailing address FOR OFFICE USE ONL t: DO NOT WRITE IV+,_IF !,.COL <br /> NAME RQb8rt D. Miller Receipt No. 4 QS Z. 00 _ <br /> 4032 CQ=ty Road 166 YTS <br /> STREET Basin <br /> CITY nizabet:h CO 07 <br /> (Zip) <br /> —... F PP <br /> TELEPHONE NO. (303) 646 4831 This well shall be used in such a way as to cause <br /> ..no material injury t4 existing--waiter-rights._The <br /> (2) LOCATION OF PROPOSED WELL issuance oll the permit does not assure the applicant <br /> that no injury will occur to another vested water <br /> Elbert right or preclude another owner of a vested water <br /> County r right from seeking relief in a civil court action. <br /> 7 ,yV1 of thawL_ A. d,Section 22 _ (1 APPYaVIM PUIIWANT TO C.R.S. 37-90-�LW7(2) AND <br /> e rr 6 p IiB tL <br /> 1) IITTU SL P IOW AND OF111 MON OF A <br /> Twp-_ S , Rn9. Fd —i�-, 6-.•► M. To D� 19 a � T PI+AN � '1U <br /> TM <br /> 1 N,SJ f F,WI �g �}- g <br /> (3) WATER USE AND WELL DATA (( ON OCpp�� �ggg Tl; $WELL <br /> DO QED IM A�i'11!$ MA�SII�"PL F <br /> Proposed maximum pumping rate(gpm) r�00 A�� BY THE STATE SMCIl1g8B OR A PLAN FOR <br /> AUGMENTATION APPROVED BY TIC WATER' COOYfi'. THE <br /> Average annual amount of ground water MATSR SUPPLY PLAN FM TIN MILL$&-BERMS PIT IS <br /> to be appropriated (acre-feet): d_3 CURRENTLY VALID 1'1NORKHi'OCT M 31 ' IM MD IF <br /> IT IS HOT E%TMED OR IF A COURT Di O IS NOT <br /> ENTERED HIDE A PLAN FOR ALOEitNTATION, THIS'•11116LL <br /> Number of arres to be irrigated: NA FMI TO >�yL -AND VOID AND ALL USE OF TOR WELL <br /> MOST E L►I►IBDIATSLY. <br /> Proposed total depth (feet), 12 2 T1D3 W'1�0TAL PO A NOT RXCM MR AM. <br /> Agvlfer ground water Is to be obtained from: THE BOMMARIiBS OF (RAVEL ND L B$ <br /> _ TRW sae ; iaT sxxsr°I .. <br /> _— Ftuiining "Creek Allavj,,01 Aquifer -'R ���d1!!R'S`HlILL 1 -WIML WELL IN A <br /> ICUOUS PLWE WITH APPROPRIATEWB PERMIT <br /> Owner's well designation M42-112 MIRD <br /> fflVWQRA%"D, T&MCMT01X'fiW0=F <br /> NMEM, NNW TER AQUIFSB AND COURT CASE <br /> AND <br /> GROUND WATER TO BE USED FOR: ow-V$E OF <br /> ( ) HOUSEHOLD USE ONLY no irrigation (0) AIMM i In <br /> DOMESTIC( )) LIVESTOCK <br /> (I) ( I INDUSTRIAL (6) QWT 1�I <br /> ( } LIVESTQGK (2) . ( )IRRIGATION(6) "' <br /> ( X) COMMERCIAL (4) ( )MUNICIPAL(8) N'AM IS ALLOW. KW% Is+tt�$f <br /> ( ) OTHER (9) APPLICATION APPROVED <br /> DETAIL THE USE ON HACK IN 01) <br /> OT <br /> (4) DRILLER �PERMITNUMBERenEW <br /> DATE ISSUE-D nf'1 2 I907Q <br /> Name NA EXPIR ION DATE `ACT 12.191Q <br /> Street <br /> •, e <br /> Ciiy (State) (ZIP) IS <br /> BY40 <br /> Tglephpne No. Lic.No. r <br /> I.D. ,__ "' 2 r —COUNTY �Z 0 <br />