REV90425

• Permit No: M1981250
• IBM Index Class Name: Revision
• Doc Date: 6/8/1987
• Doc Name: REGULAR 112 PERMIT APPLICAITON FORM
• Type & Sequence: CN1
• Media Type: D
• Archive: No

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10. Correspondance Information
APPLICANT/OPERATOR (name, address, and phone of name to be used on permit)
Individual's Name: Yuma County
Company Name: Y7,ma rounty Road Department
Street: X10 S. Slake Street
City: Wrav.
State: COLORP.DO Zip Code: 80758
Area Code: ~n3 Telephone: 332_5718
'. PERMITTING CONTACT (if different from applicant/operator above)
Individual's Name:
Company Name:
Street:
City:
State: Zip Code:
Area Code: Telephone:
INSPECTION CONTACT (if different from applicant/operator above)
Individual's Name:
Company Name:
Street:
City:
State: Zip Code:
Area Code: Telephone:
11. Primary future ^ Cropland(CR) O Pastureland(PL) ^ General Agriculture(GA)
land use ® Rangeland(RL) ^ Forestry(FR) ^ Wildlife Habitat(WL)
(check one): ^ Residential(RS) ^ Recreation(RC) ^ Industrial/Commercial(IC)
^ Developed water Resources(WR} Q Solid Waste Oisposai('WD)
12. Primary present ^ Cropland(CR) ^ Pastureland(PL) ^ General Agriculture(GA)
land use &] Rangeland(RL1 Q Forestry(FR) Q Wildlife Habitat(WL?
(check one): O Residential(RS) ^ Recreation(RC) ^ Industrial/Cmm~ercial(IC)
^ Developed Water Resources(WR)
To the best of my knowledge, all the information presented on this application torn and
the attached Exhibits A-P are true and correct (rust be s~applican /operator).
Dete: .innp 4 1487 BY' f17AJ/
C y Road Supervisor
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