2009-09-30_REVISION - M1996050

• Permit No: M1996050
• IBM Index Class Name: REVISION
• Doc Date: 9/30/2009
• Doc Name: Submittal
• From: Forrest Leaf, P.E.
• To: DRMS
• Type & Sequence: AM1
• Media Type: D
• Archive: No

Form No. COLORADO DIVISION OF WATER RESOURCES For Office Use only
GWS-27 DEPARTMENT OF NATURAL RESOURCES
6/2006 1313 Sherman St., Rm 818, Denver, Colorado 80203
Phone: [phone]
REVIEW INSTRUCTIONS PRIOR TO COMPLETING FORM
GRAVEL PIT WELL PERMIT APPLICATION
1. TYPE OF PERMIT
NEW PIT(S)
PIT(S) EXIST, CONSTRUCTED AFTER DEC. 31, 1980
2. APPLICANT INFORMATION
NAME(S) C?C- hi-
t"--Mailing Address F2 'Br
City, St. Zip C• O-I2 2

) ?L Z " J 4'1
Phone C-2-7.
3. CONSULTANT/ TTORNEY/OPERAT R CONTACT (If different than #2)
NAME(S) af'r'4S l?zs- PIT NAME q UA- ?t`
Mailing Address Cow
City, St. Zip c ?" e-? @- ?•? ?c?(& 33
DMG NO.%i_? t G " ?5
Phone ( ? '7 ® ) ; ' 3 cl (,, 3
4. GENERAL LOCATION OF PIT(S): COUNTY
NLJ 1/4 7 67 1/4, Sec. ?- Twp.---I ® N. ? S., Range 4E53 ? E. W. P.M.
5. Estimated maximum water surface to be exposed: • 5 Acres. Number of Pits j
6. Estimated depth of pit(s) ` - Ft. Estimated depth to groundwater IF Ft.
7. Estimated date to expose groundwater i ?? 1 ; to complete mining Z C-' 7--0
8. ATTACHMENTS: (Check which have been attached.)
(a) Scaled map of pit area with range, township, & section clearly identified (REQUIRED).
(b) ? Copy of the reclamation permit, if applicable.
? Copy of pre 1/15/89 water conservancy dist. or water user assoc. augmentation agreement, if applicable.
(c)
(
(d) b.l Copy of proposed substitute water plan or augmentation plan application, if applicable.
Case No.
if applicable
roved augmentation plan
of court a
) ? Co
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.
,
pp
py
e
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Other
(f)

9. Detailed description of any use, other than evaporation, and method of diversion, rate of diversion, and annual amount of
diversion of any w ter withdra n fro th . pond. ?l

10. 1 (we) have read the statements made herein and know the contents thereof, and that they are true to my (our)
knowledge. [Pursuant to Section 24-4-104 (13)(a) C.R.S., the making of false statements herein constitutes perjury
in the second degree and is punishable as a class 1 misdemeanor.]
Name/Title (Please type or print) Signature
?
&Z Date
?
&-J 4
? F
Y-'f
For Office Use only
Court Case No. Div. Co. _ WD Basin _ MD Use