REV93926

• Permit No: M1978162
• IBM Index Class Name: Revision
• Doc Date: 4/29/1987
• Doc Name: REGULAR 112 PERMIT APPLICATION FORM
• Type & Sequence: CN1
• Media Type: D
• Archive: No

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10. Corgi^espondance Information
APPLICANT/OPERATOR (name, address. and phone of name to be used on permit)
Individual's Name: RICHARD NEB
Company Name: MORGAN COUNTY BOARD OF COMMISSIONERS
Street: KIOWA AND ENSIGN STREET
City: FORT MORGAN
State: COLORADO Zip Code: 80701
Area Code: 303 Telephone: [phone]
PER;dITTING CONTACT (if different from applicant/operator above)
Individual's Name: SAME AS ABOVE
Company Name:
Street:
City:
State: Zip Cdde:
Area Code: Telephone:
• INSPECTION CONTACT (if different from applicant/operator above)
individual's Name: SAME AS ABOVE
Company Name:
Street:
City:
State:
Area Code:
11. Primary future
land use
(check one):
12. Primary present
land use
(check one):
Telephone:

Zip Code:
^ Cropland(CR) Q Pastureland{pL) O Generai Agriculture(GA)
^ Rangeland(RL) ^ Forestry(FR) ^ Wildiife Habltat(WL)
^ Residential(RS)^ Recreatlon(RC) ^ Industrial/Commerclal(IC)
^ Developed Water Resources(WR) ^ Solid Waste Disposal(WD)
I~ Cropland(CR) ^ Pastureland(PL) ^ General Agriculture(GA)
^ Rangeland(RL) ^ Forestry(FR) ^ Wildlife Habitat(WL)
^ Resldential(RS) ^ Recreation(RC) ^ Industrial/CommerciallIC}
^ Developed Water Resources(WR)
To the best of my knowledge, all the information presented on this application form and
the atta//h/ed Exhibits A-P arep~trGUe and correct (must be s gned by app/~licant/operator).
Date• L~,~~i~~i" ,L~~~,~ BY: f~~X~
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