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.wRJ-S-Re.. 76 COLORADO DIVISION OF WATER RESOURCES RECEII~E~J <br />B18 Centennial Bldg., 1313 Sherman St., Denver, Colorado 80203 s~ <br />PERMIT APPLICATION FORM_ ~7 ~\" \JAV 14 r91 <br />Application must ;J <br />ccmplete where 1 ~ 1'A PERMIT TO USE GROUND WATER <br />hcable. T WATEF. 9.i S'_'"'~ . <br />ype or (~I A PERMIT TO CONSTRUCT A WELL ~ STA-,f ~; ~: ~, <br />t in BLACK FOR: ( ,1 A PERMIT TO INSTALL A PUMP ~ ~ CCO <br />~. No overstrikes <br />or erasures unless ( I REPLACEMENT FOR N0. ~' <br />initialed. 1 )OTHER <br />WATER COURT CASE N0. <br />mailing address <br />NAME°mir•s Fe~ ~O <br />STREET /02 $O /li1FVaY /2 <br />CITY WeS><On CO 8/09/ <br />15tarel Riol <br />TELEPHONE N0. C719 ~ ~66' 2 ~6 <br />(2) LOCATION OF PROPOSED WELL <br />County- `GS r-rn i/n <br />_ /VE : of the .f/W '/., Section Z 3 <br />Twp. 33 .S , Rng. ~L ~, P_M <br />IN.SI IE.W~ <br />(31 WATER USE AND WELL DATA <br />~osed maximum pumping rate 19pm1 <br />Average annual amount of ground water <br />to be appropriated (acre-feed' 0 <br />Number of acres to be irrigated: ~ <br />Proposed total depth (feet): ~~ 9 ~ <br />Aquifer ground water is t/o~ be obtained from: <br />Wef CinY°n COQ ~ SGaM <br />Owner's well designation ~ W ~ ~ 8 - qG ~A~ <br />GROUND WATER TO BE USED FOR: <br />I HOUSEHOLD USE ONLY <br />( 1 DOMESTIC 111 <br />1 1 LIVESTOCK 121 <br />1 I COMMERCIAL 14) <br />no irrigation (01 <br />1 1 INDUSTRIAL (61 <br />( )IRRIGATION (61 <br />( )MUNICIPAL 181 <br />OTHER 191 $ase Line ltlaTer /l/eni ~or: ns <br />DETAIL THE USE ON BACK IN 111) <br />141 DRILLER <br />Name- Fin ~e•/ Uri//ina <br />•et P•~. Box 31/ <br />city I~a t<on Nm B~Yo <br />(Slate( (Zlp( <br />Telephone No(So sI YYS- S)Y1 Lic. No. <br />FOR OFFICE USE ONLY: DO NOT WRITE IN THIS COLUMNt~ <br /> r" <br />ReceiptNo.~o.?~v4/7~ / rig <br /> J <br />U <br />Basin Dist. <br /> <br />CONDITIONS OF APPROVAL !, <br /> tm <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 aswre 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 />APPLICATION APPROVED <br />PERMIT NUMBER <br />DATE ISSUED <br />EXPIRATION DATE <br />(STATE ENGINEER) <br />BY <br />I.D. <br />COUNTY ~ b _ <br />