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WRJ•S-Rev 76 COLORADO DIVISION OF WATER RESOURCES <br /> 818 Centennial Bldg., 1313 Sherman St.,Denver,Colorado 80203 <br /> RECEIvEr) <br /> PERMIT APPLICATION FORM <br /> Application must JUN 1 0 1982 <br /> be complete where 04) A PERMIT TO USE GROUND WATER <br /> applicable. Type or W ENGMIEEr <br /> A PERMIT TO CONSTRUCT A WELL ENG)NE <br /> CtL <br /> print in BLACK FOR: j A PERMIT TO INSTALL A PUMP <br /> INK.No overstrikes <br /> or erasures unless ( ) REPLACEMENT FOR NO. <br /> initialed. ( )OTHER _ <br /> WATER COURT CASE NO. <br /> (1) APPLICANT - mailing address FOR OFFICE USE ONLY: DO NOT WRITE IN THIS COLUMN <br /> NAME rfir I-. Onii cc "1- _ Receipt No. 67 7/3 _.. / <br /> STREET.6• X 1921' Basin Dist. _ <br /> CITY S1,►/Cit W(Trat)) I CONDITIONS OF APPROVAL <br /> TELEPHONE NO(301) 3244-14/4 3 This well shall be used in such a way as to cause <br /> no material injury to existing water rights. The <br /> (2) LOCATION OF PROPOSED WELL 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 /> County '—''Sit-'gf/-e/fr--f-- right from seeking relief in a civil court action. <br /> S e' < f it '/e <br /> of the � ,Section_J..> APPROVID P'OR DOMESTIC USE, INCLUDI 'G '1!!Z <br /> IL IRRIGATION OP NOT OVER ONE ACRE Or BOVE <br /> Twp. N 4/, Rng._401_ 14/ . 6 P.M. EIS AND LLUINS. <br /> N.s, 15 W) <br /> (3) WATER USE AND WELL DATA c�- <br /> Proposed maximum pumping rate(gpm) /J 34 <br /> Average annual amount of ground water <br /> to be appropriated (acre-feet): / 0,4.^ <br /> Number of acres to be irrigated: _ i_i �rfe c. , -.. <br /> Proposed total depth (feet): 3.e,--) <br /> Aquifer ground water is to be obtained from: <br /> Owner's well designation_ <br /> GROUND WATER TO SE USED FOR: <br /> ( ) HOUSEHOLD USE ONLY • no irrigation (01 <br /> DOMESTIC (1) { ) INDUSTRIAL (5) <br /> LIVESTOCK (2) ( ) IRRIGATION (6) <br /> ( I COMMERCIAL (4) ( ) MUNICIPAL (8) <br /> ( ) OTHER (9) APPLICATION APPROVED <br /> DETAIL THE USE ON BACK IN (11) n <br /> (4) DRILLER PERMIT NUMBER 126 r" <br /> JUN 2b wo <br /> �..� f� {^ DATE ISSUED <br /> IUN <br /> Name7 2) J Q-.: EXPI TION DATE .UN 2 5 '84 <br /> Street 43 el-71 '/% (( C/C:4L, �i• / <br /> Ca.t( C � ( 'TE .PEER) <br /> CityA <br /> �saT (State) Zip) Ass - i �� <br /> f �j BY ' /c / -L' <br /> Telephone No. E 4 ee 3 Z-Lic.No. tg' / y 2 <br /> I.D. � - �] <br /> gfJ COUNTY 11( _ <br />