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<br />NRJ~S~Rev. 76 <br />.Application must <br />be comple[e where <br />applicable. Type or <br />print in BLACK <br />tNK. No overstrikes <br />or erasures unless <br />Initialed. <br />U> ~~ ~.~ <br />COLORADO DIVISION OF WATER RESOURCES ~ kI ~ -- <br />818 Cantenniel Bldp., 1313 Sherman St, Denver, Colorado 80203 1'ir~'v E <br />PERMIT APPLICATION FORM RECEfVED X16'93 <br />1 A PERMIT TO USE GROUND WATER J~ 2 Z X93 <br />(~1 A PERMIT TO CONSTRUCT A WELL <br />FOR: ( ) A PERMIT TO INSTALL A PUMP <br />WA7ER nC5=1Vf!cts <br />( )REPLACEMENT FOR NO. srA71: E: ~IN~LIt <br />l 1OTHER e~- <br />WATER COURT CASE NO <br />WATER RE.+aI~'ca <br />STATE <br />~ ~i~s <br />(1) APPLICANT -mailing address <br />NAME ~~r•~'1nPr~ /<O.iMnrv n~ <br />STREET \q.~P.' ~.nt.n~4., IQrnor>! (ooh <br />CITY l~g\ ~n~e. (?~ g~~3r7i <br />[Sure) (ZID) <br />TELEPHONE N0. ~~q - ~e-"~ 7~ ~ (n 7(p <br />(2) LOCATION OF PROPOSED WELL <br />CountY~ n c /4n. Mss <br />.-,5~~ of the ,j~ F Y., Section ~'~ <br />Twp.~_ .S..Rn9•~_ ~1. ~P.M, <br />l IN.51 IE.WI <br />WATER USE AND WELL DATA <br />Proposed maximum pumping rate (gpml <br />Average annual amount of ground water / <br />to be appropriated (acre-feed: arle_ ~n ..t <br />Number of acres to be irrigated: 4t`.1 ~n n n o. <br />i <br />Proposed total depth (feed: ~~ <br />Apuifer ground water is to be obtained from: <br />(fin A n n ,. / /'1 <br />Owner's well designation <br />GROUND WATER TO BE USED FOR: <br />( 1 HOUSEHOLD USE ONLY ~ no irrigation (O) <br />I~Q DOMESTIC 111 ( 1 INDUSTRIAL 151 <br />( 1 LIVESTOCK (21 ( 1 IRRIGATION 161 <br />1 1 COMMERCIAL 141 ( 1 MUNICIPAL (81 <br />I 1 OTHER 191 <br />DETAIL THE USE ON BACK IN (11) <br />(4) DRILLER/I <br />•ame OA/Ph ~A~/ <br />Street a ~~ ~ n x __~ //9.'~ <br />city ~O •~C r~~ /P- ~ (7 S I h.~~ <br />~~ ISUUI IZ~PI <br />TNn..6....n fJ .. ~7/O-QVG-/.("1 i._ ~~ (77Y <br />FOR OFFICE USE ON~LyY: DO NOT WRITE IN THIS COLUMN <br />Receipt No. 3.SY a ~ ~ <br />Basin 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 />/~r-~! IaM'C <br />APPLICATION APPROVED <br />PERMIT NUMBER <br />DATE ISSUED <br />EXPIRATION DATE <br />(STATE ENGINEER) <br />BY <br />