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wRJ. i- R e•. 76 <br />^opliCa[ion must <br />complete where <br />licable Type or <br />t m BLACK <br />I K. No overstrikes <br />or erasures unless <br />iniltaled. <br />COLORADO DIVISION OF WATER RESOURCES <br />818 Centennial Bldg., 1313 Sherman St., Denver, Colorado 80203 <br />PERMIT APPLICATION FORM /Z4~~~' <br />f 1 A PERMIT TO USE GROUND WATER <br />( ) A PERMIT TO CONSTRUCT A WELL <br />FOR:1( ) A PERMIT TO INSTALL A PUMP <br />1 REPLACEMENT FOR NO. <br />(OTHER <br />WATEA COURT CASE N0. <br />RECEIVED <br />JGN 14 '91 <br /> <br /> <br /> <br />COLO. <br /> 4i <br /> w <br />2 <br />(1) APPLIGAN 1 -~malling atltlress <br />NAME WVa...int, Ft~ ~O <br />STREET 102 SO HIt/w.,. /2 <br />CITY WCSTOn CD B/O!/ <br />15tatel flip) <br />TELEPHONE N0. ~7/9 ~ 866-2T6I <br />(2) LOCATION AAOF PROPOSED WELL <br />County GGS //gi.~iS , <br />~% of the /V/d '/., Section 2 3 <br />Twp. 33 S , Rnq. 6 7 ~, P.M <br />IN.51 IE.WI <br />r~) WATER USE AND WELL DATA <br />~osed maximum pumping rate (gpm) <br />Average annual amount of ground water <br />to be appropriated (acre-feetl: ~ <br />CONDITIONS OF APPROVAL ,!~ <br />~; <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 />Number of acres to be irrigated: ~ <br />Proposed total depth (feet): y6 y' <br />Aquifer ground water is to be obtained from: ; <br />Wt1><•~ Coe( Seam ' <br />Owner's well designation (WL B- SD I . <br />GROUND WATER TO BE USED FOR: <br />( )HOUSEHOLD USE ONLY - no irrigation 101 <br />1 1 DOMESTIC (tl ( 1 INDUSTRIAL 151 <br />f I LIVESTOCK (2) ( 1 IRRIGATION (61 <br />1 COMMERCIAL 141 ( )MUNICIPAL 161 <br />1 "f OTHER (91 Base Liven jl/aTer //1M;~er:n~ APPLICATION APPROVED <br />DETAIL THE USE ON BACK IN (11) <br />(41 DRILLER <br />FOR OFFICE USE ONLY: DO NOT WRITE IN THIS COLUMNr- <br /> -, <br />rr <br />p <br />l ~~il 3/ 7 L7 / <br />R <br />i <br />N ti <br />r <br />pt <br />ece <br />o ! <br />U <br />Basin Oist. a <br />:-+ <br />PERMIT NUMBER <br />r DATE ISSUED <br />"-me r"'(~< <%//%~ EXPIRATION DATE <br />t P•0, ox 3Y/ <br />C~ ~at<en Nm 8))Yo ISTATEENGINEER) <br />(Slate) (Z~p) <br />Telephone NoS ~S}yy5~ Shy/ Lic. NO. <br />BY <br />I.D. <br />COUNTY ~l~ - I <br />