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'HRJ-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 />( ) A PERMIT TO USE GROUND WATER <br />l 1 A PERMIT TO CONSTRUCT A WELL <br />FOR: ( ) A PERMIT TO INSTALL A PUMP <br />( )REPLACEMENT FOR NO. <br />(x10THER Mon(+o~l n•; <br />WATER COURT CASE N0. <br />mailing address <br />NAME ~SIn Qe,fOVr~4S I <br />STREET~00 {/I~t1,WSV I1 <br />u <br />CITY 1/1/tS~on C.0• ~ 10°- / <br />(State( (ZID) <br />TELEPHONE NO. X719) BCg~ "t6 / <br />(2) LOCATION OF PROPOSED WELL <br />Cou~nt~y~/^~S A h/ h~a s <br />.~]-%. of the N -+/ '/., Section..]~_ <br />Twp.~_ ~., Rng. ~ W ~_P.M <br />1N.51 IE.VA <br />• (3) WATER USE AND WELL DATA <br />Proposed maximum pumping rate Igpml <br />Average annual amount of ground water <br />to be appropriated (acre-feed: /~A <br />Number of acres to be irrigated: Na <br />Proposed total depth (feet): - a` yS <br />Aquifer ground water is to be obtained from: <br />~gXw~l1 Goti(SBa~ <br />Owner's well designation ~ M I i - q `/ (NM ~ ( <br />GROUND WATER TO 8E USED FOR: <br />( 1 HOUSEHOLD USE ONLY <br />( )DOMESTIC (11 <br />( 1 LIVESTOCK (21 <br />1 1 COMMERCIAL 14) <br />COLORADO DIVISION OF WATER RESOURCES <br />818 Centennial Bldg., 1313 Sherman St., Denver, Colorado 80203 <br />no irrigation (01 <br />( )INDUSTRIAL (51 <br />( ) {RRIGATION (61 <br />( )MUNICIPAL 181 <br />(,() OTHER (91 t"1 011 f or a n ti <br />DETAIL THE USE ON BACK IN (11) <br />(4) DRILLER <br />.Name~f~~rPe.l" ~n/ll/n <br />Street 3 ~{ 3 6 I 41~~wa~ l1 <br />cityTrinio~rol CO• 8lb81 <br />(State) 7 IZiPI <br />Telephone No. ~11~1) RyL' iS 8 y Lic. No. - 3 ~-1 <br />FOR OFFICE USE ONLY: DO NOT WRITE IN THIS COLUMN <br />Receipt No. <br />Basin 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 />