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WRJ-S-R e.. 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 />COLORADO DIVISION OF WATER RESOURCES <br />618 Centennial Bldg., 1313 Sherman St., Denver, Colorado 80203 <br />PERMIT APPLICATION FORM <br />1 1 A PERMIT TO USE GROUND WATER <br />1 1 A PERMIT TO CONSTRUCT A WELL <br />FOR: ( ) A PERMIT TO INSTALL A PUMP <br />( )REPLACEMENT FOR N0. <br />1XIOTHER /1'-O~ifD~f~~- <br />WATER COURT CASE N0. <br />APPLICANT • mailing address <br />NAME (Sasf h /tQ,{pvr'CE1• L~1G <br />STREET -H.T00 N r~.wAY 12 <br />CITY r~?S}D~ GO• glOti I <br />(State) (Zip) <br />TELEPHONE NO. ~~(~ S6E' d ~~ ~ <br />(2) LOCATION OF PROPOSED WELL <br />County L'rls /4111I~1~f <br />SE '/. of the~VE %., Section ~ 3 <br />Twp. _t ~_ S , Rng.-~ w 6 P. <br />IN. S) IE. Wf <br />• 13) WATER USE AND WELL DATA <br />Proposed maximum pumping rate Igpml <br />Average annual amount of ground water' <br />to be appropriated (acre-feed: N A <br />Number of acres to be irrigated: N A <br />Proposed total depth (feet): ~~3 <br />Aquifer ground water is to be obtained from: <br />Max vtierll ~/ <br />Owner's well designation l ~ 3 a - rl 7 (S ti~ ^7~ <br />GROUND WATER TO BE USED FOR: <br />( 1 HOUSEHOLD USE ONLY - no irrigation (0) <br />( )DOMESTIC (11 ( 1 INDUSTRIAL (51 <br />( 1 LIVESTOCK 121 ( )IRRIGATION 161 <br />( )COMMERCIAL 141 ( 1 MUNICIPAL (81 <br />1X1 OTHER (g) h10hf r0-rte <br />DETAIL THE USE ON BACK IN (11) <br />(4) DRILLER <br />•NameJ~arpes Qr't llt~lq <br />Street?k36I HfgI~WAY la <br />r I <br />Statq IZip) <br />Telephone N o.~7 I q ~ ~y 6 as~~ 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 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 />