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r"""" "" STATE OF COLORADO <br />rr For omo. use onl <br />y <br />OFFICE OF THE STATE ENGINEER <br />oeg <br />810 Canrennial Bldg., iJ1J Sharman SL. Denver, Colorado 6020) <br />(JOJ) 666-J661 <br />PRIOR TO COMPLETING FORM, SEE INSTRUCTIONS ON REVERSE SIDE , <br />CHANGE IN OWNERSHIP /ADDRESS <br />WELL PERMIT, LIVESTOCK TANK OR EROSION CONTROL DAM <br />1. NEW OWNER <br /> NAME(S) Colowyo Coal Company <br /> Mailing Address 5731 State Highway 13 <br /> City, St. Zip Meeker, Colorado 81641 <br /> <br /> Phone (30~t ) g24-4451 <br />2. THIS CHANGE IS FOR ONE OF THE FOLLOWING: <br /> WELL PERMIT NUMBER 135483 <br /> ^ LIVESTOCK WATER TANK NUMBER <br /> ^ EROSION CONTROL DAM NUMBER <br />3. WELL LOCATION: COUNTY Moffat OWNER'S WELL DESIGNRTION84-W (84-D1-02) <br /> _14 invern cc Dr'v ac Blde. F - Sli e 2 8. .nal wood- Colorado 80112 <br /> (Addreeel (~~Hl (Stare) (ZP) <br /> Nw 1/4 orlne ~F 1/4, Sec.~S_Twp. 3 ©N. «^ S., Range 93 ^ E. or ©W. 6 P.M <br /> Distances from Section Lines 725 Ft. from ®N. or ^ S. Line, 2300 Ft. from ^ E. or ^ W. Line. <br /> ~~~~ne N-336,175, E-1,359,576 Lot Block Filing (Unit) <br />4. LIVESTOCK TANK OR EROSION CONTROL DAM LOCATION; COUNTY <br /> t/4, Sec. Twp. ^ N. o. ^ S., Range ^ E. « ^ W. P.M. <br />5. The above listed owner(s) say(s) that he (they) own the structure described herein. <br /> The existing record is being amended for the following reason(s): <br /> 0 Change in name of owner, ^ Change in mailing address. <br />6. I (we) have read the statements made herein, know the contents thereof, and state that they are true <br /> to my (our) knowledge. <br /> [Pursuant to Section 24-d-104 (13)(a) C.R.S., the making of false statements herein constitutes perjury in <br /> the second degree and is punishable as a class 1 misdemeanor.] <br />Name(fitle (Please type or print) Signature Date <br />FOR OFFICE USE ONLY <br />Srere Engineer 8y Oare <br />Court Case No. Div. Co. WD Basin MD Use <br />