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<br />i cSi ~~T ', STATE OF C~LC?~':\^<)
<br />frfVIFi04 (:? +'ATFR Ri^+iCR(.F~
<br />•tFFP:.I: O~ T11F: STitTE E`~G1?7EF,R. (=R(rL tiD W:\T it ~=-r'TC;'f
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<br />Rr~lelranl TitC C,.lnra:i•~ ''ncl and I: n;, Cn~f.n:~atlo~t ~,,,',~^•)~ ;~ ".
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<br />Dcl,th ~ 1 ft. Dlamrtrr~ 11) f t • In.
<br />\\Caaing 1E. (t Plaint 0 ft. YPrfor.
<br />i5Lltlc Rhtcr Lcvri _ _ `J__ _ - _ft. from tcp
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<br />+ Wcll wne first uaed_':trct: 19=rI .
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<br />for above usc5 using I2h gp.n
<br />tVELL TO 6E I,OCAT):D AS ACCC'P.-
<br /> and used c~~ntiruously sinco. ATELY AS POS:i7ilLE: t:ITtiT:7 A
<br />* Wcll eeilargad 19
<br />fo SI:fALL SQUARF. C:lI1CI1 REI'i;FS,Sti75
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<br />deepened', 40 ACP.ES; OH IF I;i A 'I'O'.CN OR
<br />~~ (gpm)(cfe)(fl) SL'BDIVISIC';7 FILL P' f'{E F't)'_LUtV-
<br />~l IT`G:
<br />}~ LOG SHOULD DE GIVEN ON REVERSE
<br /> SIDE IF AVAILABLE Tou•n or `~~tnivision
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<br />. Valle; Alluvis.-t
<br />~ Street address ur Lot and Filock
<br /> The above well ~rre) (has not) beer. registered in the O[ficc o[ the Gtatc E^glnecr prior
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<br /> to May 1, I9i
<br />7. It Registered give Filing No.
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<br />Lt If NOT Rrg'.stered prior to btry 1, 1957, a $S. CO filing fee accompanies this form.
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<br />Twp. .%~ R ITZC. ~. 6th ptT
<br />1'lcld 1C?•l' t-pm)(cts) trcrr 9 to ~9 tt.
<br />:;ar.ita:•y, 1[rt:[,.strlal,
<br />Geed foryC-`•~ :tls" ^n_r•t r~r', m• n.•On~lt
<br />Last .\llen '''i no of C. I: L I.
<br />(legal desr_ripticn of isrd or r.lte)
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<br />Water com•ecr~J 6y n±~^ sire 4"
<br />Type Centri`tt••,.1 Cizc 4"z.'." Apia Chalncr::
<br />40 Ii? ~. , . ~r~
<br />~ Driven by F.i~,,.si -.n .'11• ^yr0 RP`.t ,4r.;'~j:(....
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<br />Tire abuse statements arc tree and correct to the best of my knov:Ic%pc and bcliri.
<br />Subscribed and Sworn before me 7
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<br />title /~ tL rla of Drceabor ]9 53 .~ t• -~
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<br />t.Ty commisslcn expires ':" ~ !-+. i~~l ~ I Oil T:!S i;.'^'.••!"ant
<br />The Colo:ac;o !reel ..^.nd I.c~t
<br />(SEAL,) ^;'~'~.n..~'. 7~ ,LF~:__t,^'_(t~ Co:•pcration
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