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lid/lb/lbld III:175 JUJ422n'd4b JHI+'I= I)MILLINU W I-'AUt 02 <br /> LORADO.DMMON OF WATER RESOURCES Oft Use Only form Gy B-"(020pg) <br /> DWOMWO-ilAT1 ML RESOURCES <br /> 1313 SHEFMM ST,RM 818,DENVER,CO SOM <br /> phone—Into:(30S)SM587 main:(303)88t aMl <br /> fac 03 B664W B4tb.00 us <br /> GENERAL PURPOSE <br /> Wat0r,11Well Permit Application <br /> Mshvilora on rarttiase 1Mdo prlor to conrpla ft tam, <br /> The t itr MM*be'ooap~M black orbim h*cr'lt W. <br /> 1. lcant hifornte lon B'Use Of Well cheek goicable 4=" <br /> Mal 0 or eppaant r !!- �. h AOacM a detailed deem"an of uses applled tor. <br /> C/o -S4 CLA!i- Industrial 0 Other(describer <br /> p aaaraee ❑Munldpal <br /> a-3 $ � q tMaanon <br /> 'S Cornn►erdel <br /> tJ a' 7 Wsn Daf ,gwopesed) <br /> (A' )q"-U MAuI ennupt 1ptle <br /> pFn <br /> L Type Of Application (check applicable boxes) 5 ° acro4ast <br /> Construct Q <br /> Q Consct new w use ardating well TOP dWh <br /> tRherW <br /> eplace exle is wan Q Change or Increase use 1 hot 14-zx <br /> sow(aquifer) Q Rwplicatton(expired pe"t) 8-i Land On Which Ground Water WI11,8e Used <br /> p Omer Ethey, l e�91 DBUMpion(M ee p AJO seen etled in <br /> &Refer To(If applicable) <br /> Wm 5 Weller Cain ate Ita�m W reereare 1 <br /> 4.Location Of Proposed Well <br /> i <br /> CMMty pi 4esd for aoa atlsdti a ,rrmp ttrelt:troale IMUMid arras. <br /> dole A., s Aurae 8. omw <br /> SeKtlon Ta�`—More Panpe E o►W P3ndMM <br /> 3 0�: aG.; List any sour"Mor serer rlpM+�od orf fire <br /> rJrsrMlw a e�e4 son eeeuen aide en wee pre"CallY Mal III arlia)' J <br /> oZ Ft.sum[]N tgS C271 Ft,hum Q E W 9. Pro Well Driller -I""" EI nal : <br /> FW "M atly_olelarxa end tlbaetla,ban dd b ner+wn .Slgnsture Of AppiGlaattl(s)Or Authorted Agent <br /> feet direetlan TtO making of false ate herein oanatl4+ives perjury In.ltle eegard <br /> Well loraetln man orepptuca e) deores,wMch is PUnlshable as a delis 1 mledehreanar pursuant to QRS. <br /> 104(13xa). 1 hoes read the stm.win heleln.know the contents <br /> pptlarnle OPS we11 kreetlan kAemnean In IJTM rorrnet end MMM that ars trus to. MQ1 A <br /> You must dvCk OP3.urea ror rwatlred sattlnpe ee lbPa .. �1° es �k Date <br /> F�ewbe t� p <br /> Ij <br /> O Zane 12 or 13 EeWne - G O 3 isms a tlu. <br /> unee nrel be <br /> t>dm nes'be NOW= Maw q 3 its Y2 �- e <br /> t►dr MME be w ra MM ramOffice Use Ofl <br /> war OPe urtlt anal fua hrr are ale9 r6S Romew4w to met swum w MAms vs[as nap name neo no. sieraes slat. <br /> S. Pwtel On Whleh ll Will Be Located <br /> A. Legal Deeerlpgon ln+gr bs oroMead se en eeecnm.n9r ,�- Receipt area only <br /> Trans Number:3647687 <br /> 10/15/20101:58:01 PM <br /> Laura Nelsen(7) <br /> Total Trans Amt.,$60.00 <br /> CREDIT CARD <br /> Tender Amount: $60.00 <br /> B. a d.uee a weu C. caner <br /> o. ws er,<oeaa any,eel�taro� iFs pno� _ *� ro►�so� <br /> ra+e�rr. <br /> f S 33-3 33-0 0--0 G 1 Sag— Dry % WD 7" eA MD <br />