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- ..... . <br />;WR1•S~Rev. 76 <br />Application must <br />be complete where <br />applicable. Type or <br />print in BLACK <br />INK. No overstrikes <br />or erasures unless <br />initialed. <br />~OAADO DIVISION OF WATER RES~RCES <br />81 ~tennial Bldg., 1313 Sherman St., penver, Cogq~ljjo 80203 <br />PERMIT APPLICATION FORM <br />I XJ A PERMIT TO USE GROUND WATER <br />( X) A PERMIT TO CONSTRUCT A WELL <br />FOR: 1 X1 A PERMIT TO INSTALL A PUMP <br />)REPLACEMENT FOR NO <br />)OTHER <br />WATER COURT CASE NO <br />address . <br />NAME Siegrist Companies <br />C/0 Nelson Engineers <br />STREET 822 7th Street <br />CITY Greeley Colorado 80631 <br />Isutel tzlcl <br />TELEPHONE NO. X303) 356-6362 <br />(2) LOCATION OF PROPOSED WELL <br />County Weld <br />of the SW %, Section 35 <br />Twp. ~.- ~. Rng. ~.~ ~_. 6th P.M. <br />W .51 IE.WI <br />(3) WATER USE AND WELL DATA <br />~ Proposed maximum pumping rate (gpm) 300 <br />Average annual amount of ground water <br />to be appropriated (acre•feetl: "Less than 1 <br />Number of acres to be irrigated: N/A <br />Proposed total depth (feet): 20 <br />Aquifer ground water is to be obtained from: <br />f Alluvium around water <br />Owner's wel I designation S i ~g r i s t b l <br />GROUND WATER TO BE USED FOR: <br />( )HOUSEHOLD USE ONLY ~ no irrigation 101 <br />( )DOMESTIC 111 ( 1 INDUSTRIAL (51 <br />( 1 LIVESTOCK 121 ( I IRRIGATION 161 <br />( 1 COMMERCIAL 141 ( 1 MUNICIPAL I81 <br />~ FOR OFFICE USE ONLY: DO NOT WRITE IN THIS COLUMN <br />Receipt No. <br />Basin <br /> <br />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 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 />1 1 OTHER (91 Dus[ control for oravel I gPPLICATION APPROVED <br />DETAIL THE USE ON BACK !N 111> operat I on. s. <br />14! DRILLER <br />PERMIT NUMBER <br />DATE ISSUED <br />Name Licensed I EXPIRATION DATE <br />Street <br />City _ _ I (STATE ENGINEER( <br />Telephone No. Lic. No. I BY <br />I n ._ rru ql I ~. <br />