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IU I!D/2uid i17: b5 JUJQ2Zn Job JHIYZZ) DMILLINU UU r,;-out UZ <br /> COLORADO DMSION OF WATER RESOURCES mice Use Only Form GWS 45(oMWS) <br /> DENT OR NATURAL RESOURCES <br /> 1313 SHERMAN ST.,RM 818,DENVEK CO 80203 <br /> phone-info:(303)86MS87 main:(303)866.3581 <br /> fax 303 988.9589 :ihMwvr. —tta:oo_us <br /> 'tiNERAtL PURPOSE <br /> 4ter'Well Permit Application <br /> ftvww kw t w lone on revs; w tilde prior to completing tom. <br /> Tlte'fantr mint be completed In Week or blue fnk or'typod. <br /> 1. Applicant Information 6:Use Of Weil tcheck applicable boxes) <br /> Name of applicant y� Abaci a detalled description of uses applied for. <br /> a .�� R a industrial [I Other(dascribe): <br /> Malting address E] Municipal <br /> ;C3 Q Irrigation <br /> city st 71,ON 000 <br /> a- f�Commerdal <br /> U 4 7:Well Data(proposed) <br /> npnone <br /> FIA19fTvrt1 pit�hp rats Annualn�nl�l't0 bA Vllthd�9Wn <br /> I 5 gpm <br /> ecf�i8et <br /> 2-Type Of Appllcation (check applicable boxes) Tofel doom Atntiter <br /> �] Construct new wall ❑Use adsting well �- y <br /> Replace wdeting well ❑Change or Increase use feet <br /> Change source(apulfer) ❑Reappticetion(expired permit) 8.1 Land On Which Ground Water Will So Used <br /> ❑Other. E 2f L.e�81 Description c?m ee mwoded as an a tarlon- <br /> 3. Refer To (if applicable) <br /> Wen tt !J(Q Waear cau,case a <br /> 14 <br /> Cxwgratee 9226 oqw""wdM Wei re-m or a <br /> 4. Location Of Proposed Weil <br /> - (if Used for cm lmpertlari.attach a scared—p ttrgt shows lMg06d ar&%) <br /> camq A- B. t7wrrrtr <br /> '�W 1-of the ancras S W i a � <br /> i <br /> $eplon Tow wrap N or a Range @ S <br /> or W Prfndpei^ ion J <br /> 3 0 �7 a ❑ L►` C.� u t any eu%w waft or water nprw L&W on fife terra: <br /> a or PIK from secuw I: rbs) <br /> a kq tj Ft.horn C]N IW S Ft.fruM D E 9. Pro s@d Well Driller Licensed onal : <br /> w <br /> For mPpteCerr"nt wells oruy-alsuanca end*soon From dd watt to mewwati � 1 . Slgnatture Of Applicant(s)Or Authorized Agent <br /> feet direction �making of false statsments heroin txxlidlvb9s perjury In the sepond <br /> was loraeon deareas prapprca e) d ree,Which les punishable as a lass 1 mledemewor pursuant to GR.S. <br /> 2,�-0-104(13)(a). I have read ft stetemants hereln.know the contents <br /> Optionelt (PS wall locatan Information In LrrM format thrim4 and state that th ate true tom knoWled e. <br /> You must ch rk OPS unit for required sel tga as foilom; ergo here t be ure) Date <br /> Format mitt be UTM P 101115 <br /> 13 zancla 13 Eeating to D 3 nsma& <br /> unit mtmt be tea [�� C{��Q (� <br /> Wom mat ba NAM N vrt/ring f r��r.Z 1� � � (' O W{'ti <br /> U.dt must be tm ro biro Marc 001ce Use On <br /> Was caps um eRe&W far abmaP rES Ronterhbarr to set Ovum to NADe3 usos map r+an* NM rnap rro. slmsea alay. <br /> S. Parcel On Which W II Will Be Located <br /> A. Lsgel Deacrippon rosy be voweee to en ertecnnwnq; Receipt ergo Ot11y <br /> I <br /> brans Number:3647687 <br /> 10/15/2010 1:58:01 PM <br /> Laura Nelsen(7) <br /> Total Trans Amt.$60.00 <br /> CREDIT CARD <br /> j Tender Amount. $60.00 <br /> Wo' ✓ <br /> 8. ■of ems In penal C_ owner W <br /> D. vo ors at re o,y wo m"s pww?PRTES ONO - er,ms) Togo,r <br /> .rs PArad tftdt(otrtlonall; _ MYLnR--"`(' <br /> 18 33-3 33-0 0-p 1 1 S85— DrV / WD � MC) <br />