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o.o ~,.menn~a~ niuo.. Is a an-rman m., Ue over, ~oloredp 30209 <br />apal~~anon oust <br />ix c - w:z ~:.n,~.e <br />apPLeable Type Or <br />pnn; BL~~CK <br />I `I II NO JVC~SCi~iS <br />om1 nasures unless <br />~.alch. <br />PERMIT APPLICATION FORM <br />1 X1 A PE RPAIT TO USE GRO UND '~'(ATEP, <br />1 I n PERrvtIT TO CONSTRUCT A WELL <br />FOR' 1 XI A PE Rh1IT 70 INSTALL A PUMP <br />1 (REPLACEMENT FOR NO <br />I 1 OTHER <br />WATER COURT CASE fJO. <br />(1) APPLICANT ~ madmg address <br />NAf.IE Ferr Coal CcrtPan'.• <br />5T R'tET r.v. oux o <br />CITY c~aldcn Colorado R0~90 <br />Isuia ¢ m <br />TELEPHONE N0. 303-723-4721 <br />• <br />121 LOCATION OF PROPOSED WELL <br />County JdCk50n <br />s~ attached sheet <br />.. of Ihe. S, Section <br />Twp _ Rng. P n7 <br />ir+9 iE1w <br />131 WATER USE AND WELL DATA <br />Proposed maximum pumping rare I9pml lUU _ <br />Average annual amount of ground water <br />to be approprialetl (acre leetl. RR <br />Number al acres to be imgated. Nnnc+ <br />Prooosetl total depth (teed: 250 naxuntun <br />Agmfer ground water is Io be obtaned from: <br />Owner's well designat ron N2W P1t Well <br />GROUND WATER TO BE USED FOR: <br />1 1 HOUSEHOLD USE ONLY ~ no in igal ion 101 <br />( XI DO~`A ESTIC 111 IX 1 INDUSTRIAL 151 <br />1 1 LIVESTOCK IZI I I IRRIGATION 161 <br />1 XI COM h1E RCIAL lal 1 I MUNICIPAL IBI <br />1 XI OTHER 191 A7 T nthor cac <br />DETAIL THE USE ON SACK IN 1111 <br />(4) DRILLER <br />Name See a to rer7 chew c <br />Street <br />City <br />Is~,~a lam <br />Telephone, Nn Lie No. <br />FOR OFFICE USE ONLY' DO NOt WRITE IN 7HIS COL UAIN <br />Receipt No / <br />eosin _ Di:! <br />ONDITIONS OF APPROVAL <br />This well shall be used in such a way as to cause <br />no material injury [o existing water rights. The <br />issuance of the permit does nUt assure the applicant <br />that no injury will occur [o 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 />E %PIRATION DATE <br />(STATE ENGINEE RI <br />BV <br />LD <br />COUNTY <br /> <br />