PERMFILE100910

• Permit No: C1981010
• IBM Index Class Name: Permit File
• Doc Date: 12/11/2001
• Doc Name: Water Rights
• Section_Exhibit Name: APPENDIX Q SECTION XVIII
• Media Type: D
• Archive: No

.FRJ 25 It I
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THIS FORM MUST BE • • V V i ' '
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SUBMITT ED PRIOR TO
THE E%PIRATION OF T COLORADO DIVISION OF 1YATER RESOURCES
HE _

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PERMIT. TYPE OR 30D Columbine Bldg.
1845 Sherman St. .
i"'

PRINT IN BLACK INK. , s _
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COPY OF ACCEPTED Denver, Colorado 80203 ~~~ i
-MENT MAILED
T
ouEST. STATE OF COLORADO ) AFFI DAVI =,~~
} SS ~;
COUNTY OF ^O{fat ) a?~t.`•E~~~
X STATEMENT OF BENEFICIAL USE OF GROUND WATER
AMENDMENT OF EXISTING RECORD
THE AFFIANT(S) Utah International
whose mailing
address is 550 California Street
PERMIT NUM6ER O1°672-F
~.
LOCATION OF WELL
c o~„r y
I.offat
IiE ~.: or rl,e 1:rY 1,, s,r,ie„ 27
City San Francisco California °4104 I Tr,p. 6 N R„9, 91 1'J 6th P.M
15}.1[) ltlvl IN Ov 51 IE Oi M1~
being duly sworn upon oath, deposes and says that he (they) is (are) the owner(s) of the well described hereon; the well is
located as described above, at distances of 1130 feet from the IvOrth section line and 2530 feet from the
Iv o.r. on aoJ*+1
East section line; water from this well was First applied to o beneficial use for the purpose(s) described herein on the
1[a• ow wrsrl
day of .luly 24 19 75~ the maximum sustained pumping rate of the well is BO gallons per minute, the pumping
t/
r •'laimed hereby is 80 gallons per minute; the total depth of the well is 1132 feet; the average annual amount
of water to be diverted is 80 acre-feet; for which claim is hereby made for Industrial and donestic
purpose(s); rthe legal description ~oF~ihe land on which the water from this well is used is
i~2 of Lot 2; Sit of Lot 3• SEi4 of Lot 4• E/: Df in+ 5; tit 6,7 Section 27, T6I:, P,91ti which totals
146.72acres and which is illustrated on the mop on the reverse side of this form; that this well was completed in compliance
with the permit approved therefor; this statement of beneficial use of ground water is filed in compliance with law; he (they) has
(have) read the statements made hereon; knows the content thereof; and that fhe same are true of his (their) knowledge.
~y/~ n ~
Signature(s) _ /`\ ~ l _ ~ : ~ „~~ ~2 _ -
Subscribed and sworn ~" _
to before me on this Gr day of .,~<'t 19=`5
My Commission expires
If[..I
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-- .or.e..~e uc
ACCEPTED FOR FILING BY THE STATE ENGINEER OF COLORADO
PURSUANT TO THE FOLL0IYING CONDITIONS:
v
FOR OFFICE USE ONLY
Cogs Case No.
Prior. Mo. _ Doy _
Dir. Cry.
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Dias. -_- Bes:n
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Mon. Dis.
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