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WRJ-$~Re~. 16 COLORADO DIVISION OF WATER RESOURCES <br />818 Centennial Bldg., 1313 Sherman St., Denver, Colorado 80203 <br />PERMIT APPLICATION FORM_ <br />Application must <br />• be complete where ( ) A PERMIT TO USE GROUND WATER <br />applicable. Type or ( ) A PERMIT TO CONSTRUCT A WELL <br />print in BLACK FOR: ( 1 A PERMIT TO INSTALL A PUMP <br />INK. No overstrikes <br />or erasures unless ( )REPLACEMENT FQR NO. <br />initialed. (~() OTHER A10~1 i l~(1''i <br />-~ <br />WATER COURT CASE N0. <br />(1) <br />ng <br />NAME Bg'f1 ^ R eSO~ Ater' ~r~ G <br />STREETjN300 H~~Nay !~ <br />CITY W~TGn Go. 81051 <br />(state) flip) <br />TELEPHONE NO. X115 ~ $ 6 8~2 ~6 / <br />(2) LOCATION OF PROPOSED WELL <br />County ~F f A ~, ~ ~, ti r <br />~~ll_% of the/ L.~/ '/., Section/~ <br />Twp.3L S , Rng. G 1 ~'/ 6 P.M, <br />IN,SI IE. WI <br />• (3) WATER USE AND WELL DATA <br />Proposed maximum pumping rate (gpm) <br />Average annual amount of ground wateN A <br />to be appropriated (acre-feed: <br />Number of acres to be irrigated: N <br />Proposed total depth (feed: ~ 6 <br />Aquifer ground water is to 6e obtained from: <br />Owner's well designation SI• 3 3 - 1 ~ ` ~ f <br />GROUND WATER TO BE USED FOR: <br />( 1 HOUSEHOLD USE ONLY <br />1 )DOMESTIC (11 <br />( 1 LIVESTOCK 121 <br />I 1 COMMERCIAL 141 <br />no irrigation 10) <br />( 1 INDUSTRIAL I51 <br />( )IRRIGATION 161 <br />( 1 MUNICIPAL 181 <br />1XIOTHER 191 /~Onf~prrn5 <br />DETAIL THE USE ON BACK IN (11) <br />(4) DRILLER <br />. Name S~Gr•peS ~!`/1jlnG <br />Street ~ a'1 j 6 ~~1 1 N ~t~_I ~ <br />cityJr~n ~ dc,d Cn 81og ~ <br />(State) (Zip) <br />Telephone No. ~ f q 5 Lic. No. (~ ~ 3 <br />FOR OFFICE USE ONLY: DO NOT WRITE IN THIS COLUMN <br />Receipt No. <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 prec{ude 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 n rn nairv <br />