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wr:J•~,R...1'a COLORADO DIVISION OF WATER RESOURCES <br /> 818 Centennial Bldg., 1313 Sherman St., Denver, Colorado 80203 <br /> (, ,~.D PERMIT APPLICATION FORM R C I ED <br />Application must <br />be complete where C' ~JV ~r~r~ <br />~ \9D~ F~~ <br />1 1 A PERMIT TO USE GROUND WATE$ I <br />plicable. Type or <br />Int in BLACK ~ 1 <br />t~ p<_5 <br />t <br />t ` <br />~ jX) A PERMIT TO CONSTRUCT A WEL ~ ~~ <br />( 1 A PERMIT TO INSTALL A PUMP ~~ ~~ <br />~ <br />N K. No overstrikes W <br />' <br />~E fNO <br />~' <br />or erasures unless > <br />~ ( )REPLACEMENT FOR N0. <br />initialed. _ ( )OTHER <br /> WATER COURT CASE N0. <br />R EIVED <br />F °~ i~so <br />~7$ YBOURCFS <br />~E FlIGIBEFA <br />address <br />NAME <br />v <br />STREETI1 d Gc_praa~ ~jtn rrr~ <br />CITY ~~/FS/One. ~OIO• S/09~ <br />lsusel tzlo) <br />TELEPHONE NO. <br />(2) LOCATION OF PROPOSED WELL <br />County 'td S A h i M1 S <br />~. F:. %. of the n._ ~ . '/., Section ~~ <br />i N.51 I E.V/I <br />13) WATER USE AND WELL DATA . <br />~oposed maximum pumping rate Igpm) /l1 Cr.PI~7 <br />Average annual amount of ground ter y <br />to be appropriated (acre-feed: ~ Qr• f~ ~QO/ <br />Number of acres to be irrigated: r10 /IF_ <br />Proposed total depth (feet): /00 <br />Aquifer groundwater is to be obtained from: <br />,~ _ .. <br />(/n-- 1(^n ~u r? <br />Owner's well designation <br />GROUND WATER TO BE USED FOR: <br />1X1 HOUSEHOLD USE ONLY <br />{ 1 DOMESTIC 111 <br />1 1 LIVESTOCK 12) <br />1 COMMERCIAL 141 <br />no irrigation 101 <br />1 INDUSTRIAL (51 <br />I 1 IRRIGATION 161 <br />1 MUNICIPAL (81 <br />1 1 OTHER 191 <br />DETAIL THE USE ON BACK IN 111) <br />14) DRILLER <br />Name AIEX t)O~C[.I <br />~eet n ~• I~o x a2 9.T~i p+ <br />City ` nK [aQ L~ l d/O. e/~~~ <br />(State) tZ~ol <br />Telephone No. na /7 F- Llc. No. ~/ 9 <br />FOR OFFICE USE ONLY: DO NOT WRITE IN THIS COLUMN <br />Receipt No. ~/ <br />Basin Dist. <br />'~ ok CONDITIONS OF APPROVAL <br />P~'' <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 />APPROVED FOR HOUSEHOLD USE ONLY, FOR Ot?IE <br />(1) SINGLE FAMILY DWELLING AND NOT TO BE <br />USED FOR IRRIGATION. THE RETURN FLOW FROtJI <br />THE USE OF THIS WELL MUST BE RETURNED TO <br />THE SAME STREAM SYSTEM IN WHICkJ THE 1NELL <br />IS_ LOCATED. <br />" ~, M7NICIP4L OR COUNTY GOVERNIdENT <br />SHALL BE CONSULTED WHEN LOCATING <br />THIS WELL, AND THEIR REGULATIONti <br />SH.U,L BE C011lPLIED KITH. <br />E~CPIRED~ <br /> <br />APPLICATION APPROVED <br />PERMIT NUMBER 11339141QQ <br />DATE ISSUED IY'QR ~1 1JVo <br />I.D. L ~ Y COUNTY ~~L' <br />