PERMFILE126562

• Permit No: M1983013
• IBM Index Class Name: Permit File
• Doc Name: PERMIT APPLICATION FORM
• Media Type: D
• Archive: No

.-. -.
WR)~5 Rr~. 7G ~LORADO DIVISION OF WATER RES~RC ES
818 Centennial Bldg., 1313 Shaman St., Denver, Colorado 60203
Application must
be complete where
applicable. Type or
print in BLACK
INK. No overstrikes
or erasures unless
initialed.
PERMIT APPLICATION FORM
1 1 A PERMIT TO USE GROUND WATER
( 1 A PERMIT TO CONSTRUCT A WELL
FOR: 1 1 A PERMIT TO INSTALL A PUMP
( IREPLACEMENTFORNO.
1 1 OTHER
WATER COURT CASE N0.
(1) APPLICANT -mailing address
NAME _
STREET
CITY
tsia~el (Zip)
TE LEPHONE NO.
121 LOCATION OF PROPOSED WELL
County
of the %, Section
Twp. __, Rng._~___ P.M
i N,9 IEW~
131 WATER USE AND WELL DATA
Proposed maximum pumping rate Igpml _
Average annual amount of ground water
to be appropriated (acre-feet!:
Number of acres to he irrigated:
Proposed total depth (feet!:
Aquifer ground water is to be obtained trom:
Owner'S well designation
GROUND WATER TO BE USED FOR:
1 HOUSEHOLD USE ONLY ~ no irrigation (Ol
( 1 DOMESTIC 111 ( 1 INDUSTRIAL 1~1
1 1 LIVESTOCK 121 ( )IRRIGATION 161
4 I COMMERCIAL 141 1 1 MUNICIPAL 18)
( 1 OTHER 191
DETAIL THE USE ON BACK IN (111
14) DRILLER
Name
Street
City
Telephone Nn _ _
-- t" N,.
FOR OFFICE USE ONLY: DO NOT WRITE IN THIS COLUMN
Receipt No
Basin
Dist
CONDITIONS OF APPROVAL
This well shall be used in such a way as to cause
no material injury to existing water rights. The
issuance of the permit does not assure the applicant
that no injury will occur to another vested water
right or preclude another owner of a vested water
right from seeking relief in a civil court action.
APPLICATION APPROVED
PERMIT NUMBER _
DAT~ISSUED
EXPIRATION DATE
!STATE ENGINEERI
8~'. _ .. _._ .._