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Form No. COLORADO DIVISION OF WATER RESOURCES For Office Use only <br />GWS-27 DEPARTMENT OF NATURAL RESOURCES <br /> <br />&2006 <br />1313 Sherman St., Rm 818, Denver, Colorado 80203 _ <br />RECEIVED <br /> Phone: (303) 866-3581 <br />1?EVfEW INSTRUCTIONS PRIOR TO COMPLETING FORM MAY 1 2008, <br />GRAVEL PIT WELL PERMIT APPLICATION <br />tYAYcFCAfl?a23tti25 <br />1. TYPE OF PERMIT sf"Tr`N61NEEP. <br />V <br /> I'm <br /> NEW F tT(5) <br /> -- PIT(S) EXIST, CONSTRUCTED AFTER DEC. 31, IM <br />2. APPLICANT INFORMATION <br /> NAME(S) <br /> <br /> Mailing Address _ <br /> City, St. Zip-- ?LlC7?- <br />? <br />-? <br /> - <br />- <br />- <br />Phone {_ D ) 7-4 <br /> <br />3. CONSULTANT/ATTORNEY/OPERATOR CONTACT (If different than #2) A/ <br /> NAME(S) j4- <br />PIT NAME <br />S ?/ <br />A <br /> Mailing Address _ <br />_ <br />_ <br />! n <br />r <br /> City, St. Zip ?T-- -? > D M G NO. <br /> <br /> Phone <br />4• GENERAL LOCATION OF PIT(S): COUNTY <br /> --- <br />1/4, Sec. Twp. b ON. ? S., Range C1 9 ? E. 19 W. (J P.M. <br />5. Estimated maximum water surface to to exposed: 0, ACI t13. IVluTiber of Pits t ' e, <br />-8. I Estimated dgXb of pit{sj??s? 'ID Ft. Estimated depth to groundwater Ft. I <br />1 7. J Estimated date to expose groundwater _ ;to complete mining <br />I o <br />v ?EN <br />ref Ml,.t11VIGY I S. t0heck which nave been attached.) <br />I <br /> <br />I I I <br />N Scaled map ? of it area with ranga township, & section clearly identified (REQUIRED). I <br />? ? <br /> (b) Copy of the reclamation permit, if applicable. <br />t I <br />i f t t_ 1 <br />i Copy of pre 1/15/89 water conservancy dist. or water user assoc. augmentation agreement, if applicable. I <br />(c) i <br /> ( <br />I I (d) I__I Copy of proposed substitute water plan or augmentation plan application, if applicable. l <br />i (e) LJ Copy of,court approved?au mentation plan, if applicable. Case No. <br />I (f) l J Other .s..r ?.-.? ?. 6 A <br />1 9. 1 Detailed description of any c:se c*har fhan °uannrafir, i arzrl mtfir. l r,f divor.zEnn Faro of Hn.aP?sAn. fts en?ca?a.. ?;,?..f...r. <br />diversion of any water withdrawn from the <br /> <br /> <br /> 5 Ac V r V /ETA t%J <br />1 <br />1U..1 - <br />! ;we) have read the stateme, :s made harain and know the `ante rits tlier,6 , and that they are true to my (our) 1 <br />f knowledge. jPursuant to Section 24-4-iU4 (13)(a) C.R.S., the -making of false statements herein constitutes perjury; <br />I in the second degree and is punishable as a class 1 misdemeanor.] <br />Nameiii iile (Please type or prim') i Signature Uate <br />1 <br />17 r':1f9' s!? wit "e / A.t.As. I 1 !Yl A 41 1,41 <br />?'yrw?eB 0 V A <br />For Office Use only <br />l <br />Court Case No. Div. Co. i WD Basil, _ Mn Use <br />i