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WRJ-S-Rey. 76 <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 />(11 APPLICANT -mailing <br />PERMIT APPLICATION FORM <br />1 A PERMIT 70 USE GROUND WATER <br />1 1 A PERMIT TO CONSTRUCT A WELL <br />FOR: ( y A PERMIT TO INSTALL A PUMP <br />( 1 REPLACEMENT FOR N0. <br />(x) OTHER n'16n1_ ~6/~t ~? <br />WATER COURT CASE NO. <br />NAME S0.S)+, S~U''<2S 1pG <br />STREET1y30~ ~{,wQy Id <br />CITY WCS4o.. CD• $(091 <br />(State) (Zip) <br />TELEPHONE NO. ~~(~~ 86S"~16~ <br />(2j LOCATION OF PROPOSED WELL <br />ty lrN s <br />un <br />C <br />o An i n, ct S <br />/ <br />~, <br />C <br />~ '/. of the SE 'G, Section <br />Twp. 3 3 S, Rng. v L_ w <br />IN,SI IE, WI <br />• (31 WATER USE AND WELL DATA <br />Proposed maximum pumping rate 19Pm1 <br />Average annual amount of ground water AA <br />to be appropriated (acre-feet): NK <br />Number of acres to be irrigated: NA <br />Proposed total depth (feed: S/0 <br />Aquifer ground water is to be obtained from: <br />p~/2r5y~d¢n ~Qh>(y~1~ <br />a~ <br />Owner's we11 designation NM 1 ~ ~ 1 y ~ NM d D~ <br />GROUND WATER TO BE USED FOR: <br />( 1 HOUSEHOLD USE ONLY <br />)DOMESTIC 111 <br />( 1 LIVESTOCK 121 <br />)COMMERCIAL 141 <br />COLORADO DIVISION OF WATER RESOURCES <br />818 Centennial Bldg., 1313 Sherman St„ Denver, Colorado 80203 <br />no irrigation (01 <br />( )INDUSTRIAL (51 <br />1 IRRIGATION 161 <br />1 )MUNICIPAL 181 <br />1X1 OTHER (91 iMbAl~Dr'I n~ <br />DETAIL THE USE ON BACK IN 111) <br />(4) DRILLER <br />. Name S~,G ~~?Q f• ~i-i ~~r <br />Street ~ `13 61 N i 5~ ~ ~+`s ~~ I ~ <br />city ~r~r+iol~d Co. BfoR~. <br />i5tatel I P~ <br />Telephone No. C) 1~1~ B~G~ ~~Lic. No. 1 ~ Z ; <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 />