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WRJ-5-72, COLORADO DIVISION OF WATER RESOURCES <br /> 101 Columbine Bldg.,1845 Sherman St., Denver, Colorado 80203 <br /> PERMIT APPLICATION FORM <br /> Ar '" 9tion must (� <br /> b plete where (X ) A PERMIT TO USE GROUND WATER w�ir1K <br /> ap, .ole. Type or (X ) A PERMIT TO CONSTRUCT A WELL STATIRM <br /> print in BLACK FOR: (X ) A PERMIT TO INSTALL A PUMP tl <br /> I N K.No overstri kes or erasures unless ( ) REPLACEMENT FOR NO. <br /> initialed. <br /> ( ) OTHER <br /> (1) APPLICANT - mailing address FOR OFFICE USE ONLY: DO NOT WRITE IN THIS COLUMN <br /> NAME Victor R. & Carolyn E. Martin Receipt No. 7 ZD—o ! <br /> STREET Rt. 6, BOX 475 Basin Dist. <br /> CITY Golden Colorado 80401 <br /> (State) (zip) CONDITIONS OF APPROVAL <br /> TELEPHONE NO. 277-0136 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 /> Clear ;Creek right or preclude another owner of a vested water <br /> County right from seeking relief in a civil court action. <br /> S W y4 of the N W '/4, Section 33 APPROVED FOR DRINKING AND SANITARY FACILITIES <br /> ONLY IN AN INDIVIDUAL (1) MANUFACTURING PLANT. <br /> Twp 3 s Rng 72 W 6th P.M. THE WELL MUST BE CONNECTED TO A CLOSED SYSTEM <br /> AND ALL RETURN FLOW FROM THE USE OF THE WELL <br /> (3) "'rATER USE AND WELL DATA MUST BE RETURNED TO THE STREAM SYSTEM IN WHTCH <br /> THE WELL IS LOCATED. <br /> i'..EGD. H G 'I'� r �FxrE+��• <br /> Proposed maximum pumping rate (gpm) 15 weapED -��`�'7if <br /> TWO (2), MONTHS E NS ION E, J I ON DATE <br /> Average annual amount of ground water TO SEPTEMBER 18, 1975. <br /> to be appropriated (acre-feet): <br /> Number of acres to be irrigated: N.A. <br /> Proposed total depth (feet): <br /> 200 <br /> Aquifer ground water is to be obtained from: <br /> granite <br /> Owner's well designation _._ N.A. <br /> GROUND WATER TO BE USED FOR: - <br /> ( ) HOUSEHOLD USE ONLY - no irrigation (0) <br /> ( 1 DOMESTIC (1) } INDUSTRIAL (5) <br /> ( ) LIVESTOCK (2) ( ) IRRIGATION (6) <br /> ( ) COMMERCIAL (4) ( ) MUNICIPAL (8) <br /> ( ) OTHER (9) industrial non--consumptive APPLICATION APPROVED <br /> 20 ,000 al. per year. 3 rest rooms ►y n <br /> g P y� drinking Water PERMIT NUMBER ` 0119 <br /> (4) DRILLER � <br /> DATE ISSUED �UL 1 8 973 <br /> Na--- NORRIS & SONS DRILLING COMPANY EXPIRATION DATE JUL 18 JQX <br /> St. _4599 North Broadway <br /> Boulder Colorado 80302 <br /> City ::,�k (Trff INEE <br /> (State) (Zip) .00 <br /> 442-�4083 716 BY <br /> Telephone No. Lic. No. <br /> I.D. COUNTY �O_ <br />