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wR~•s.lt.:.'1a COLORADO DIVISION OF WATER RESOURCES <br />818 Centennial Bldp., 1313 Sherman St., Denver, Colorado 80203 <br /> <br />Application must <br />be complete where <br />applicable. Type or <br />print in BLACK <br />INK No overstrikes <br />or erasures. unless <br />initialed. <br />PERMIT APPLICATION FORM <br />(r%('A PERMIT TO USE GROUND WATER <br />(~ A PERMIT TO CONSTRUCT A WELL <br />FOR: ( A PERMIT TO INSTALL A PUMP <br />( )REPLACEMENT FOR NO <br />( )OTHER <br />WATER COURT CASE NO <br />~ (1) APPLICANT • mailing address <br />I FCCt=n <br />NAME s TIUll ~ <br />ice' 1-\W t O yL`i~. <br /> (~ <br />( <br />p <br />STREET-~'W ,kk~Pt+ F(~G-ER~~"~RCS.tJ~F2 <br /> tt~~ ~u\CE 53 <br />' CITY Etablb s .D \r ~h\11 _-- <br />• (e total <br />(2io1 <br /> p <br />TELEPHONE N0. ~3- °~~- U~1$ <br /> POSED <br />(2) LOCATION OFP <br />RO <br />W <br />ELL <br /> ( <br />^ <br />'j <br />~7 <br />County Y 7Y J <br />• ~ ~ % of the Y., Section <br /> Twp. ~ ~, Rng, ~, ~/ ~P,M <br />' <br /> I N,51 IE. WI <br /> (31 WATER USE AND WELL DATA <br /> /, <br />Proposed maximum pumping rate (gpm) ~/ O <br /> Average annual amount of ground water Lam' <br />0 <br /> to be appropriated lacre~feetl: y.) <br /> _ <br />,1 <br />Number of acres [o be irrigated: /V ~ ~I~ ~- <br /> Proposed total depth Ifeetl: ~ Q 0 <br /> Aquifer ground water is t <br />o be obtained from: <br /> y <br />O /' ~~L L <br /> Owner i well designation <br />~ GROUND WATER TO BE USED FOR: <br /> ( )HOUSEHOLD USE ONLY ~ no irrigation 101 <br /> ( 1 DOMESTIC (11 ~ ( 1 INDUSTRIAL (BI <br /> ( 1 LIVESTOCK 121 1 I IRRIGATION (61 <br /> ()((COMMERCIAL 14) ( )MUNICIPAL (81 <br /> I I OTHER 191 <br />~ DETAlL THE USE ON SACK !N (11) <br /> LER <br />141 DRIL <br /> p <br />A/ ~~ ~A Sf k/00 <br /> Name- <br /> Street .~ ~ ~ ~~G <br /> City ,ar.L'/I'Tl"A~% C O~Q ~0~03 <br /> f oral <br />ILOI <br /> •I~-,/ // <br />C~ <br />/~ <br />Telephone Na./ 6 9"75 ? ~ Lic. No. 'T ~i <br />FOR OFFICE USE ONLY: DO NOT WRITE IN THIS COLUMN <br />Receipt <br />Basin <br /> <br />Dist. <br />ONDITIONS OF APPROVA <br />This well shall be used in such a way as to cause <br />no material injury to existing water rights. The <br />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 />right from seeking relief in a civil court action. <br />APPLICATION APPROVED <br />PERMIT NUMBER <br />DATE ISSUED <br />EXPIRATION DATE <br />(STATE ENGINEER) <br />BY <br />I.D. <br />COUNTY <br />~~ <br />