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. ,•~~.~ ~ "-= COLORADO DIVISION OF tNATER RESOURCES ~t~IVLI`ICI1 <br /> 107 Columtline 81dg., 7645 Sherman St., Denver, Colorado 6020#'~ <br />~'V~ <br /> ~ ~20r77 <br /> PERMIT APPLICATION FORM <br />-- h~14,78 kt <br />a <br />Auphcau on must TiATta a:%UU <br />' <br /> <br />be complete where <br />1 I A PERAUT TO USE GROUND WATER tTATL EII(:SltEdt <br />applicable. Type or DPI A PERA7IT TO CONSTRUCT A WELL WATER RESOURLg C7L9, <br />print ~ in BLACK fOR: ( ) A PERMIT TO INSTALL A PUMP ~)F OIGIHEER <br />INK. No overstrikes ma <br />or erasures unless ( )REPLACEMENT FOR NO. <br />initialed. <br /> ( )OTHEA <br />{1) APPLICANT • mailing address <br />NAr,tE~rT+crt P Grcf <br />STREET / Bex vT <br />CITY p }~ ~n~o} d+~n Ct/6 ~ S <br />ISwq iLPI <br />TELEPHONE NO. ~ 1 `/ ' .300$ <br />(2) LOCATION OF PROPOSED IVELL ' <br />GOImtY //1 0 C l- z l <br />/ <br />T .vp.~_ h_. Rng ~_ ~L. E Th P.h1 <br />(3) TVATER USE AND WELL DATA <br />Proposed maximum pumping rate (gpml .S ()~ ~ i( nh <br />Average annual amount Of ground s•+ater <br />w be appropriated lacre~teetl: I ac Y ~ F_•aT <br />rJUmber of acres to be irrigated: <br />P~oposetl total depth (leetl: /rX! 1; '1C0 <br />Arluiler ground water is to be obtained from: <br />Owner's well designation /~ ~ ~rJ C S Tr L <br />GROUND WATER TO BE USED FOR: <br />( 1 HOUSEHOLD USE ONLY <br />L`Cl DOMESTIC l11 <br />1 1 LIVESTOCK (21 <br />( 1 COhthtERCIAL hl <br />no ungation 101 <br />1 1 INDUSTRIAL lbl <br />I 1 IRRIGATION (GI <br />( 1 r.tU.":ICIPAL IB1 <br />( I OTHER 191 <br />(4) DRILLER <br />Name <br />. Sheet <br />Gty <br />t5rnel IL~PI <br />Tclcnhone No. <br />(~ I ce use <br />Lic. No. <br />FOR OFFICE USE ONLY: 00 NOT WRITE IN THIS COLUMN <br />t <br />Receipt No. /G ~' / / <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 v.~ill occur to another vested water <br />riyht or Itreclude another owner of a vested water <br />right from seeking relief in a civil court action. <br />APPEO r4~J FOE D0.'IESTIC USE, IYCLUDI2IG THE <br />IERICATIOt1 OF 270T 0~%it 02,x' 9CFu OF H03SE <br />GAID~S AFD L9'At)S . <br />APPLICATION APPROVED <br />PE Rh11T NUh7BER ~) ~ ~ ` ~~ <br />DATE ISSUED ~~N 161977 <br />E;(PIRATIi. TE ~~ ^^JUN l~~ 1979 <br />W~ • - <br />,~~//~j~~~'p~-IS ATE ENGINEER) <br />i .... .. __ _.__-._ _..__ __ <br />t/~I~rIS <br />