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<br />WRJ~S~Re~. 76 COLORADO DIVISION OF WATER RESOURCES 111 ~II~II~II ~~II III <br /> 818 Centennial Bldg., 1313 Sherman St., Denver, Colorado 80203 999 <br /> /~. c~(~~ <br />~L~! Y P.~1r,,lY <br /> PERMIT APPLICATION FORM <br />Application must <br />be complete where <br />( 1 A PERMIT TO USE GROUND WATER ,~~~IIrr~~ <br />N)"n ~ ~ r~°1 <br />applicable. Type or 1 1 A PERMIT TO CONSTRUCT A WELL <br />print in BLACK FOR: ( 1 A PERMIT TO INSTALL A PUMP t:~pp:;;;y_y-L's.CF.: <br />INK. No overstn kes SiRTf Fv'*:A:25 n <br />or erasures unless IX 1 REPLACEMENT FOR N0. rol0 <br />initialed. IXIOTHER:eEev°-~ u.,7e <br /> WATER COURT CASE N0. <br />mailing address <br />NAME ~:om, Inr. <br />STREET 9145 Sunshine Cannon Rd <br />clrv Boulder Co 80302 <br />TELEPHONE NO. ~303)~+9-771[6 <br />121 LOCATION OF PROPOSED WELL <br />County Rnnl rler <br />NPl % of the SEi! Y., Section 12 <br />Twp. ~~ ,Rng. 72W W P.M. <br />I N,51 IE.WI <br />131 WATER USE AND WELL DATA <br />Proposed maximum pumping rate Igpml <br />Average annual amount of ground water <br />to be appropriated (acre~feetl: <br />Number of acres to be irrigated: <br />Roposed total depth Ifeetl: <br />0 <br />Aquifer ground water is to be obtained from: <br />Left Hand Ditch (See Map) <br />Owner's well designation <br />Access Hole <br />GROUND WATER TO BE USED FOR: <br />1 1 HOUSEHOLD USE ONLY <br />1 1 DOMESTIC 111 <br />1 1 LIVESTOCK (21 <br />1 I COMMERCIAL 141 <br />no irrigation 101 <br />1 INDUSTRIAL (51 <br />( 1 IRRIGATION 161 <br />( 1 MUNICIPAL 181 <br />IX I OTHER (91_A(,`ress Hnic <br />DETAIL THE USE ON BACK IN 111) <br />141 DRILLER <br />Name Grnnnrlwater Systems <br />Street 4599 N. Broadway <br />City Boulder ~'o RO n~ <br />( late) (Lp) <br />Telephone No. (303, 44 -408.8c. No. 963 <br />(FOR OFFICE USE ONLY: DO NOT WRITE IN THIS COLUMN <br />Receipt No_~37Sa3 / <br />Basin <br />Dist. <br />CONDITIONS OF APPROVAL <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 />"~~~I Y 1~. ~.j <br />QPr7 13 199? <br />Mined Land <br />i~P.Rl2n,afl7n rlr,,:.,; <br />~ APPLICATION APPROVED <br />PERMIT NUMBER <br />DATE ISSUED <br />EXPIRATION DATE <br />(STATE ENGINEER) <br />BY <br />I.D <br />COUNTY <br />