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RECEIVED <br />'xRJ•5-Re.. 76 COLORADO DIVISION OF WATER RESOURCES <br /> 618 Centennial Bldg., 1313 Sherman St., Denver, Colorado 80203 <br /> JAY 14'91 <br /> PERMIT APPLICATION FORM <br />Application must WATER RESOURCES <br />• complete where ~ ( I A PERMIT TO USE GROUND WATER STATE E?:;,;N`r,~ <br />COLO <br /> <br />~icable. Type or <br />t m BLACK <br />' <br />(N'A PERMIT TO CONSTRUCT A WELL ~~~/ <br />(G I <br />~ <br />FOR: ( 1 A PERMIT TO INSTALL A PUMP . <br />,t /I <br />'t~ 1 <br />I K. NO Overstrikes l <br />VV <br />l <br />3 <br />or erasures unless ( 1 REPLACEMENT FOR NO. <br />initialed. ( (OTHER <br />WATER COURT CASE NO <br />(1) APPLICANT -mailing address <br />NAME WYpn+~LA FGI Cd, <br />STREET /o2S0 f/r;~~[±i+~y /L <br />CITY ~(/G{tow CO 809/ <br />., (state) alp) <br />TELEPHONE NO. `~~ (~ Ig~°8~ Z76I <br />(2) LOCATION OAF PROPOSED WELL <br />County L~aS An:nsiS - <br />/y~ %. of the `S~ '/., Section Z7 <br />Twp.~3 ~. Rng. 6 ~ W P.M. <br />~N.Si iE.w~ <br />(3) WATER USE AND WELL DATA <br />~osed maximum pumping rate (gpml O <br />Average annual amount of ground water ~ <br />to be appropriated (acre-feed: <br />Number of acres to be irrigated: <br />i <br />Proposed total depth (feet): ~~~ <br />AQuifer g/round water is to be obtained from:.. <br />WeSf+pn Cx ~ .SPsM <br />Owner's well designation• W~ ~''-YO ~~~~~~ <br />GROUND WATER TO BE USED FOR: <br />1 1 HOUSEHOLD USE ONLY - no irrigation (01 <br />1 1 DOMESTIC Itl ( 1 INDUSTRIAL (51 <br />1 LIVESTOCK (21 1 1 IRRIGATION 161 <br />( 1 COMMERCIAL (4) ( 1 MUNICIPAL (81 <br />OTHER 191 Base Liwe_ N~/'e-~ /rt/ni~in <br />DETAIL THE USE ON BACK IN (11) <br />141 DRILLER <br />Name Ofillins <br />~t p.0, aox 3 Fr' <br />(State) a~pl <br />Telephone N~$JS) yyS- S ~y~ Lic. No. <br />e <br />~. <br />FOR OFFICE USE ONLY: DO NOT WRITE IN THIS COLUMN" <br />ReceiptNol~/~/7.q / f~• <br />~i <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 righu. 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 />.. <br />APPLICATION APPROVED <br />PERMIT NUMBER <br />DATE ISSUED <br />EXPIRATION DATE <br />(STATE ENGINEER( <br />BY <br />COUNTY ~~ - I 1 <br />I.D. <br />