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WRJ'S-Rev. 76 CDL~ADD DIVISION OF WATER RESOU~ <br />818 Centennial Bldg., 1313 Sherman St., Denver, Colorado 80203 <br /> PERMIT APPLICATION FORM <br /> <br />Application must _ <br />be complete where ( ) A PERMIT TO USE GROUND WATER <br />applicable. Type or ( I A PERMIT TO CONSTRUCT A WELL <br />print in BLACK FOR: ( ) A PERMIT TO INSTALL A PUMP <br />INK. No overstrikes <br />or erasures unless ( I REPLACEMENT FOR N0. <br />initialed. ( )OTHER <br /> WATER COURT CASE N0. <br />(11 APPLICANT -mailing address <br />NAME <br />~ STREET <br />CITY <br />' (State) (Zip) <br />TELEPHONE N0. <br />(2) LOCATION OF PROPOSED WELL <br />' County <br />'/, of the '/., Section <br />Twp _, Rng. P.M. <br />W.S IE 1VI <br />131 WATER USE AND WELL DATA <br />Proposed maximum pumping rate Igpm1 -_ <br />Average annual amount of ground water <br />to be appropriated (acre~feetl: <br />Number of acres to be urigated: _ <br />Proposed total depth (feet): <br />Aquifer ground water is to be obtained from: <br />'~ Owner's well designation <br />i GROUND WATER TO BE USED FOR: <br />I ( I HOUSEHOLD USE ONLY - no irrigation 101 <br />~ ( 1 DOMESTIC 111 ( 1 INDUSTRIAL 161 <br />1 1 LIVESTOCK 121 1 1 IRRIGATION 161 <br />1 COMMERCIAL (41 ( 1 MUNICIPAL IS) <br />1 I OTHER 191 <br />DETAIL THE USE ON BACK IN 1111 <br />141 DRILLER <br />Name <br />Streei <br />City <br />(Sla\e) (Zip) <br />Telephone No. Lic. Na. <br />~ FOR OFFICE USE ONLY: DO NOT WRITE IN THIS COLUMN <br />Receipt No. <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 will occur to another vested water <br />right or preclude another owner of a vested water <br />right from seeking relief in a civil court action. <br />APPLICATION APPROVED <br />PERMIT NUMBER _ <br />DATE ISSUED <br />EXPIRATION DATE <br />(STATE ENGINEER) <br />BY <br />I.D <br />COUNTY _„ <br />