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4 <br />COL RADO ION OF WATER RESOURCES Office Use Only Form pwS~s (trsoot) <br />DEPORTMENT OF NATURAL RESOURCES <br />1313 SHERMAN 3T., RM 818, DENVER, CO 80203 <br /> <br />ptxme - iMo: (303) 8!1&3587 main: (303) 888.3581 e1~ <br />f~~(.~~UCv <br />tax: 03 888-3589 h :/hvww.wa[ar.efale.eo.us <br />GENERAL PURPOSE <br /> MAY ~ 12002 <br />Water Well Permit Application <br />Review Instrue8oro on reverse aid. prior to eempleting form. ~ ,ty,~pltgs~"'°D <br />1Er~ <br />1T. form must tM wmpNted in t5yck Ink, g1A <br />1. scant IrtfortnaUon 6. Use Of Well check a Bcable boxes <br />"'"'aipi°°it Attach a detailed descdptbn of uses app8ed br. <br />and L Mit:abitD ^ indusiriai ®other(des«lbe): H <br />usehold <br /> <br />~ <br />~' o <br />, <br />' <br />Post Office Box 34 ^ MuMdpal I.ivestack watering, <br />~ ®rr <br />i <br />ti <br />' <br /> ~~ ga <br />r <br />on (,See Rtx3alentation Plan, OOCA <br />297 <br /> • 82 ^Canmercial attached) <br />Ti11p°" 7. Well Data (Proposed) <br />970 887-9319 <br /> <br />2. Type Of Applicadon (cneck apptigbfe boxes) Mndrnum a^~V+9 raV rwM n,wna,a.augra.n <br /> 1.5 aaedeet <br />^ Conshucl new well <br />®use exisdng wed <br />_ T,W <br />aacSr . Maaw <br />_ <br />^'Replece'exkting web ~ ~ Change or inaease use X1Blatel 75 (eel Tribute <br />^ Charge source (aquifer) ^ ReappBCauon (expired pennil) 8. Land On Which Ground Water Will Be Used <br />C11 Omer: <br /> A <br />L <br />l D <br />i <br />i <br /> . <br />ega <br />escr <br />pt <br />on pryaam.id.dran allwn,wrd): <br />3. Refer.To (if applicable) <br />wapmra waMdaunaaee Great Divide Head Lettace Colony <br />130733 5-00-Cw-297 (Attached) Tract 3 <br />orpel.d aaw Oaaminaeona wee more ae <br /> Mirabito Well No. 1 <br />4. Location Of Pro osed Well nr used ipraap xrig9em, anem a araled mep met chows iripeled eroal <br />COPd/ B. rAaar C. Omw <br />Gret>d -t~--"'d"' *~ '" 10.00 (A .) Mark & LiBa Mirabito <br />Scram To,nul:p NaS <br />3O <br />6 Rwga EaW Ri~pal laukwn <br />76 ^® 6 <br />D. uaaryawrwW awaW dye. vaW mlNSbM: <br />31 t <br />2 ~ <br />pawuaweeanaaam awpremaxn an sslmynot Wr~wrY a»a) N/A <br /> <br />c. e.., ~ H D s 1650 ra sea m E D w 9. Pro sttd Well Drl Iler License tional <br />'~°"p°""°wi°°~d'-tl~vsin0°V°onM1andO"`00p'"°ra0 tO.SlgnatureOFApplicanl(s)OrAuthorizedAgent <br />feel direction The mekirp of false cktemente herrin wrls5lulea perjury in the second <br />wMwron.awntr.rer'.n.) degree. which is punidlable as a doss 1 misdemeanor p11r5110rs to C.R.S. <br />443 C.R. 631 Gran CO 80446 24d-104 (13xa). 1 have read ma statements herein, krgw me contents <br />OWknel: GPS wee bcettat MiornxuWr to U7M format erd stale that re'We to krawled e. <br />Repaired sssige for GPS unit arenlorows: sP I"wt os 1 Dao <br />raarn.all»urw 5/20 02 <br />7arw rwN solo Nonning Pret n • ~~~ - <br />UO oast 4 area <br />wae.mmwNnonteonust <br />Eaur <br />Mark or Lisa Mirabito <br /> g <br />~ Office Use Only - <br />tar mwsearnsus aeM <br />Ww.Paadaa,era0adt ^YE9 ^NO USGS map nor OWN map no. SWar. aNV. <br />5. Paresi On WMch Well Will Be Located <br />A Lapel Deeaigion luwy lu pMdadr>t etlarlnrnj ReeNpt area oHy <br />Great Divide Head Lettace Colony <br />Tract 3 <br />Camty of Grand <br />State of Colorado invoice W ~~~.~ ~ <br /> 5/31/82 <br /> Gshter 1D: B1 <br /> 1 68.88 <br /> PBtCllaee- <br />l <br /> C t <br />wE gleC <br />B./asvr ii parul . Owror <br />10.00 (Approx.) Mark & Lisa Mirabito wN <br />D. Wn Waeaaa dNr vaem eda Wrarrr YES NOld rq-rlewa wb) CWCB <br /> TONG <br />E. sur r.,oaiav (apaavll: Ae'w' q <br />'~ ~ B <br />MD <br />( <br /> % VYD <br />A __ <br />Se5 DIV <br />