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Form<No. COLORADO DIVISION OF WATER RESOURCES For Office Use only <br />GWS-27 DEPARTMENT OF NATURAL RESOURCES <br />6/2006 1313 Sherman St., Rm 818, Denver, Colorado 80203 <br /> Phone: (303) 866-3581 <br />REVIEW INSTRUCTIONS PRIOR TO COMPLETING FORM <br />GRAVEL PIT WELL PERMIT APPLICATION <br />1. TYPE OF PERMIT <br /> NEW PIT(S) <br /> ? PIT(S) EXIST, CONSTRUCTED AFTER DEC. 31, 1980 <br />2. APPLICANT INFORMATION <br /> NAME(S) M. A. CoNe_r_erE GON-smye- IoN we.. <br /> Mailing Address 2323 R1I%JE12, RoAD <br /> City, St. Zip eQAsio JuNe-no G.n $1 SOS <br /> Phone L -'?70 ) 243 -,S57-1 <br />3. CONSULTANT/ATTORNEY/OPERATOR CONTACT (If different than #2) <br /> NAME(S) SAME PIT NAME <br /> <br /> Mailing Address <br />DMG NO. <br /> City, St. Zip .4S0VE <br /> Phone ( ) <br />4. GENERAL LOCATION OF PIT(S): COUNTY ME: .5 )k <br /> JE 1/4 V E 1/4, Sec. 23 Twp. ? N. 0 S., Range__J_ 0 E. ? W. UTE P.M. <br />5. Estimated maximum water surface to be exposed: Acres. Number of Pits <br />6. Estimated depth of pit(s) 10 Ft. Estimated depth to groundwater 6 Ft. <br /> Estimated date to expose groundwater- vNti ?I 04 ; to complete mining 3vcJE1-1 zo14 <br />8. ATTACHMENTS: (Check which have been attached.) <br /> (a) ? Scaled map of pit area with range, township, & section clearly identified (REQUIRED). <br /> (b) ? Copy of the reclamation permit, if applicable. <br /> (c) ? Copy of pre 1/15/89 water conservancy dist. or water user assoc. augmentation agreement, if applicable. <br /> (d) ? Copy of proposed substitute water plan or augmentation plan application, if applicable. <br /> (e) ? Copy of court approved augmentation plan, if applicable. Case No. <br /> ? Oth <br />f <br /> er <br />( <br />) <br />9. Detailed description of any use, other than evaporation, and method of diversion, rate of diversion, and annual amount of <br /> diversion of any water withdrawn from the pond. <br /> <br /> <br /> <br />10. 1 (we) have read the statements made herein and know the contents thereof, and that they are true to my (our) <br /> knowledge. (Pursuant to Section 24-4-104 (13)(a) C.R.S., the making of false statements herein constitutes perjury <br /> in the second degree and is punishable as a class 1 misdemeanor.] <br />Name/Title (Please type or print) <br />MARTIN Aze-A RiL*.6A Signature Date <br />owNER. % 12- 22. U <br />For Office Use only <br />Court Case No. Div. Co. _ WD Basin _ MD Use <br />r <br />L <br /> <br />