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<br /> <br />E CF COLGFACG <br />~FiCc CF i rE 5 ~ r~ i e E:VGifJE== <br />X19 Camennml 31ag.. t3t3 Sherman St.. ~smer. ~ororaCO 3C: <br />I~0_1 d6o-Z=81 <br />rt INSn'UC'iCNS. gL nE'/E~SE SIDE <br />trot Ctfice Use mW <br />' STATE:4IENT OF GENE=iCIAL USc 97rEC~ 5° ~ <br />r <br />WE1 PE:;Mff NUMBF~ ?C.~(r~ - i•• <br />CWNE? <br />~ <br />' <br />S ri ~ t~ l ( <br />C M I~ n l \ <br />NAMES) (' ~ Y <br />ling Acare <br />s <br />s '>. -~ <br />/ <br />~ <br />thane (~; ,~~? - ~~( ~GJ <br />~! LCCA7ICN: CGUNT( L ~~ I C'~ CWNE='S WE_ GE3iG~ lA i iGN <br />(Aaaraea/ Kfi'1 (5~1 IZPI <br />~1/4 of ffie~_1 /4, Sec.~_ Twp. ~ ©N, or ^ S., R <br />a <br />n <br />ge___~[_+~ ^ E or ©W. f1 P.M. ~, <br />y <br />- <br />/ <br />.ances from Secion Lnes ;~ 1 ~b Ft. from ©N. or ~.! S. Line. 1 ~ C Ft. from ©E or 0 W. Line. <br />~.. <br />I e well is being used for the foltawirtg purpose(s): L /w )U t?2 ~ .~ L , C mm E2 C r n L ~.•,/f r s i i~ <br />c T ~ I Lr22i (- r ~ <br />ter from the Weil was firs used beneficially <br />d <br />ib <br />d <br />~ <br />Z ~ <br />9 9 7 <br />escr <br />e <br />purposes on _~ <br />1 <br />I <br />. <br />under this pertni[ number, for the above <br />! not reecrt a daro wnicn ~a before ~s issued data of ffiu pertnrtf <br />pumeing rate claimed is In c~ galtens per mincae. <br />e average annual amount of •xater diverted is ~ "~] acre `eat <br />Ttte land area irrigated (watered) by water :`ram this well is' 1GU ®Acres or ^ Square feet, <br />(Numosy <br />~c:ibed as: / tAT'~i n' Tel ~ i~i~ ~~ - rJ .SfC~ SJ ' c /~ P <br />~ egu ueaenFaonl <br />~ Sut:division Lat(s) Elock Fiing/Unit <br />e(I drilled by: ( 2 !- n _ r~. Lc. No: /..~C 7 <br />` <br />Lic. Na: ~. <br />mo instilled by: 2 r ~ ~c ~ n ~. 1 ~ ~ 7itl <br />ter Mfc. by Serial Nc.: Date Installed: <br />we) have read the satements made herein, know the oortterrcs t`.erzcf, and state that they are true to my (cur) <br />~ <br />cwledse. [Fursuartt to Se~.ien 24-,L-10a (~3)(a) C.A.S., the making of falsa statements here{n consitutes perjury <br />In the szc~nC decree anC is punishable as a Class 1 misdemeancr.) <br />Name:TRte {P!eaae type or pony <br />'E ~• Dire ~ C .~ ~ ,~~~~tst;+z~J <br />G~ isn ' e L. j <br />r ~`"`L-~ } <br />U Dale <br /> <br />~/ <br />- ?7 <br />~ <br />l <br />cc Q • !- r• r_ v ~Al Y t 2 1 <br />0 <br />FCF. GF=SCE USE ONLY ~ <br /> <br /> <br /> <br /> <br />$tal0 G9Ca InCef BY O4[e <br />Coutt Case No. Civ. Co. WG Eosin MD Use 1 <br />