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+~ Arl...r `. f f. ~ f7, . <br />COl4RAC0 CiillStOi~ CP ~vn.fE1 RESCIU^CES °~,:...:(,.'.~.'. ~' I <br />tree or 4' A~ ].0 L~b..l;er r}1; WtS $I~.rr.rn St .. '~ L.---^ ., <br />Cu-• ~/ •r:tTi6 Ore•.r, CaleraG+ i+ii~)1 ~ ~~~ ~-~ <br />ow +rot'n[ SfaTE Of COIOkADO I A',,,... .;~r ~~~ f,~;:~~~,r! ( <br />COUNTY CF _` ; SS ..~...~".._r..l'-'(' ` ,, <br />-r..__ ,..__. ~.,. -. - ~ <br />STATEMENT Ot OEr1EFICIAL USS CI GROU~!D •ATER <br />AxS~HDraEMT 0? EAISTii1G R.'r:CGr~D <br />n.c r ,e- <br />LAT! RflGISTRATION .. ' <br />nr3 /... <br />PEG7tITNIbnJER4`~,~~7.4=~ LOCATI^.'10'wrLL ~~ <br />Rr <br />ME AFFIANTISI _ Jahrs Ate' ~o~_ _!_ G..., _ _ Iti0.An1--'Z.-___ __ - <br />.hese ma.l.ny '. - <br />eddrru rs ~ 2r_ I!1_]! I!i 0 .._ .__ -.' __- .r. _._ e ._ 7.. <br />ar- .-'_?~roa,.~':~a-T7C~-- - •.. _3i_ -?-- `°' --G3-...r)j:: f~~. <br />,... .r... . , .. <br />i <br />6r ~y duly sworn rpon oath, deposes a.d says riot he (theyl .s tart) the awnwf sl of the wril dw..drd hers^. .hr .•:I .. <br />lecorrd as drur~brd abo•r, at d~va~crs of (rrt Item th.._ _~ srct~an Imr a-d ____- (r•r Low •~- j <br />sect;on I~no; water Irani this we~l ros I~rsf applied to o benel~c gal utr Ice she v~+t».~I ci destr,~ri h-r~ , c+ r1~ ?1 <br />day of .~^r•_ 19 ~(, the mesrmum sastams! pump~ny rate of the +ell .s v'~..._ysllons ptr m~cu}e, t!•e pv+~p~• t <br />rate da~mrd Mrrby '~ - `"zj _ yollens pu n..nure, the tetol depth n) the .ell rs 29 Irer, the o.rroyr c++ral ate:,-• ~!~ <br />of earn to by deer tad .s LSD ccrv~lrvr; la. wh~ch ua.m rs hreby made for !rr!asLien, tl ^.'^^~!Cy_,y^y?: <br />_ .. .. i <br />>Y ^?+~y'11r!_1tTe Ovrposei sl; tM legal de.cnot~on of rhr lord on ~h~c6 the ..tree Lc- th~a ••e'I .s ,.sad ~. j <br />... ^L. ~_ al ~~..'. <br />erxu a.v lnlymed ertd witch Is illvstrotad on thv map on rhv rerenv sldv of this brm; thtn this ail wa C_vplnrd .+ i <br />~;" evmplianca with thv permit epp'rrrd thtrrafor; Nsis statement of benvficlnl use o~ yraund warn is 1.1-d .n ee-pli^ncr with law, hs ! <br />` Ithry) has (hare) rind tt:v stotemr:srs mode hereon; krrows thv eontnt thortol; end shat tie same ere teas of his (^-o:r1 kno.le?;~. <br />(CC7APLEiE REVERSE :IDE OP T111S FORAS) ~ ' <br />S;ynotwrl s) <br />Subscribed atd sworn soa Grrr:; csr o~+t.r <br />to 6etore my ten this drsy of _ , 19__. r <br />Mr Cor+mros;on r.prres: _, ~ J <br />ACCEPTED FOR ftLtttO 9Y TttE STATF. ENGINEER OF COlORA00 ; f <br />PUR;UaNT TO TIIE FOLLC~xtNG CONDIT10;:; i <br />ern un ~! -. .1. -'~ ~ _ <br />~~ <br />