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WRJ~S-Rev. 16 <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 />( 1 A PERM)T TO USE GROUND WATER <br />( 1 A PERMIT TO CONSTRUCT A WELL <br />FOR: ( ) A PERMIT TO INSTALL A PUMP <br />1 REPLACEMENT fOR NQ. <br />(XI OTHER /HOnIfOr"r~a <br />WATER COURT CASE N0~ <br />COLORADO DIVISION OF WATER RESOURCES <br />818 Centennial Btdg., 1313 Sherman St., Denver, Colorado 80203. <br />mailing address <br />NAME B~S11 Reso~~cps T., c. <br />STREET_I.~~~O I'~IF~tWGV fl <br />CITY WeS'~0., ~.~ $I0~1 <br />~t 1G (Stara) IZIP) <br />TELEPHONE N0~ u.3 ~ ~ `8- at ~ L <br />(2) LOCATION OF PROPOSED WELL <br />County ~ti5 An~r.~r <br />~~_'/.Cof the~~1_'/., Section ~~ <br />1 N, SI I E.wl <br />131 WATER USE AND WELL DATA <br />•'. <br />Proposed maximum pumping rate (gpm) <br />3 <br />Average annual amount of ground water <br />to be appropriated (acre~feetl: N.~ <br />Number of acres to be irrigated: N Q <br />Proposed total depth (Teed: t' ~ V <br />Aquifer ground wlater is to be obtained from: <br />QVC~`vl-G{Prt ~ot~~~)~ <br />Owner's well designation ~~E 7 ~- ~ S ~~~ w ~1 ~~ ) <br />GROUND WATER TO BE USED FOR: <br />( 1 HOUSEHOLD USE ONLY - no irrigation 101 <br />1 )DOMESTIC 11) ( )INDUSTRIAL 1~) <br />1 LIVESTOCK (2) ( 1 IRRIGATION 161 <br />1 COMMERCIAL 14) ( 1 MUNICIPAL 181 <br />IXIOTHER191 Monl~o/'tn5 <br />DETAIL THE USE ON BACK IN (11) <br />141 DRILLER <br />. Name ~~+r+i' 12.C Qri ~~; n^ <br />Street 3 `1 6 r Hr~~ h/Ety 1 ~ <br />city?r~,,;d~d Co glot~ <br />(State) (ZIP) <br />Telephone No~~l~ ~kb uQa~ Lic. No. ~ ~ 13 <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 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 rl r~/111.ITV <br />