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,''G7 K <br />4R.I.S~R e.. 715 COLORADO DIVISION OF WATER RESOURCES RF(~~{VED <br />' 818 Centennial Bldg., 1313 Sherman St., Denver, Colorado 80203 <br />PERMIT APPLICATION FORM I49~R 1 Sr92 <br />Application must <br />complete where Ix) A PERMIT TO USE GROUND WATER ::~.'•.:'CES <br />pplicable. Type or iX 1 A PERMIT TO CONSTRUCT A WELL _ <br />print in BLACK FOR: 17t 1 A PERMIT TO INSTALL A PUMP "'~ <br />INK. N o overstr i k es <br />or erasures unless 1 1 REPLACEMENTFOR N0. ~~~~ /~ <br />initialed. 1 1 OTHER ~/~ <br />WATER COURT CASE NO. ~; <br />r. <br />~( (1) APPLICANT • mailing address <br />NAME NfUG~ ~G~TwII YIGs\ <br />STREE((T~~ 1S~2Z wo~cllc~aJeJ <br />CITY L~Cl~a trC Tx 77'4b <br />l Isutel tzlol <br />TELEPHONE N0. 7i3./ G 6 7 S Z-J" 8 <br />(2) LOCATION OF PROPOSED WELL <br />County I.ab <br />1'11i' '/. of the ~ '/., Section 11 <br />Twp. '> 33 S Rng. 67 W 6th P.M <br />.. ~ "' IN.51 - - IE.WI <br />~3) WATER USE AND WELL DATA <br />Proposed maximum pumping rate (gpm) _ <br />Average annual amount of ground water <br />to be appropriated lacre•feetl: <br />Number of acres to be irrigated: NGNE <br />Proposed total depth (feed: 200 <br />Aquifer ground water is to be obtained from: <br />Taramie Sandstone <br />Owner's well designation <br />GROUND WATER TO BE USED FOR: <br />1 I HOUSEHOLD USE ONLY ~ no irrigation (01 <br />(XI DOMESTIC (11 ( I INDUSTRIAL IS) <br />;1X1 LIVESTOCK 121 ( 1 IRRIGATION (61 <br />l 1 COMMERCIAL 141 ( 1 MUNICIPAL IBI <br />1 I OTHER 191 <br />DETAIL THE USE ON BACK IN 111) <br />(4) DRILLER <br />APPLICATION APPROVED <br />PERMIT NUMBER <br />DATE ISSUED <br />~ame Alex Bodav I EXPIRATION DATE <br />veer P.O. Box 8 <br />C;ty Bon Carbo, Colorado 81024 <br />isurel (zoo) <br />Telephone No <br />71 9-846-6412Lic. No <br />15 <br />FOR OFFICE USE ONLY: DO NOT WRITE IN THIS COLU <br />Receipt N~J ~ ~ `t/ / <br />Basin <br />Dist. - <br />.. ~, <br />CONDITIONS OF APPROVAL <br />This well shall be used in such a way as to cause ! <br />nc 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 />(STATE ENGINEER) <br />819 BY // /~ <br />LD. ~ COUNTY ~K' <br />