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<br />No.~ DEPARTMENT O~URAL RESOURCES <br />GWS-27 <br />12N6 1313 SAermen SZ., Rm 81 a, Deriver, Colorado eD203 <br /> p~M; (3051 eC0.3Ge1 <br />REVIEW INSTRUCTIONS PRIOR TO COMPLETING FDRM <br />G RAVEL PIT WELL PERMIT APPLICATION <br />. TYPE OF PERMIT <br /> NEW PItISI <br /> ^ PIT(5) EXIST, CONSTRUCTED AFTER DEC. 31, 7880 <br />2. APPLICANT INFORMATION <br /> NAMElSI- 1~11TED CrlJA1PRNIES OF MES/t c/~cJNr~ InIC <br /> Mailing Address x9273 RIyEP RoA d <br /> Cily,St•Lp ~,PANd ~UNt?TIDfJ CD ~15D5 <br /> Phone ( 470) ~`E3 k9©O <br />3. CONSULTANTlATTORNEYIOPERATDR CONTACT (If different then N21 <br /> <br />NAMEISI ll~(o LEUItCFl~ n <br />PIT NAME f ICEA NcE pl'i- <br /> MaiGng Address 40a`'`;' S, FORREST dRIJ~ <br /> City, St. Zip Ff!(ofFtANQS ,EAAIc.~ .r~ 80/,~ DMG NO. ~ ~ %~O ~ - O77 <br /> Phone (~1 ~34(., S! 96 <br />4. GENERAL LOCATION OF PITISI: COUNTY Rln &A Yn <br /> NUJ 1/4 I~It7 1 /4, Sec.~_ Twp. ~ ©N. ^ S., Range ~ 7 ^ E. ©W. l P.M. <br />5. Estimated maximum water 6urtace to be erq~ased: 4.2 Acres. Number of Fits / <br />6. Estimated depth of pitlal 02~ Ft. Estimated depth to groundwater 3 Ft. <br />7. Estimated date to expose groundwater PT .20Df ;to complete mining NotlE/rier~ .zop3 . <br />8. ATTACHMENTS: (Check which nave been attached.) <br /> Ia) ©Scaled map of pit area with range, township, & aeCtibn clearly indentked (REQUIRED)- <br /> Ibl ^ Copy of the reclamation parrna, if applicable. <br /> Ic) ^ Copy of pre 1/1 S/89 water consernncy dirt. or water user assoc. augmentation agreement, it applicable <br /> Id1 ^ Copy of proposed substi4rte vaster plan or augmentation plan application, ii applicable. <br /> (el ^ Copy of court approved augmentation plan, ff applipble. Case ND. <br /> (f) ®Other ,~IIIIP)E <br />9. Detailed description of any use, other than evaporation, and method of diversion, rata of diversion, and annual amoun <br /> bf diversion of any water whhdrawn from the pond. <br /> SEE ATTAC'NED .I)E6~Rlf'TlOh1 OF t15ES, <br /> <br /> <br />0 I Iwe) have read the statements made herein and know the contents thereof, and that they are true to my (our) <br /> knOwledBe• [Pursuant to Section 24-4-104 it3)(a) C.R.S., the making of false statements herein Constitutes perju <br /> In the second degree and is punishable as a Class t mistlemeanor.] <br />NamelTtle !Please type or pArnl ignewra <br />' Date . <br />L~E6 Lf-G.1iG<f /~6inlE~l~ / <br />U g g ~( <br />For Offioe Uce only <br />Court Case No. Div. ~ Co. ~ wD !Basin _ MD ,Use <br />