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. E OF PERMIT
LI NEW PIT(S)
P PIT(S) EXIST, CONSTRUCTED AFTER DEC. 31, 1980
2. APPLICANT INFORMATION
NAME(S)
Mailing Address
City, St. Zip 6 ao -f Z 2
Phone( 7O
3. CONSULTANTI TTORNEY/OPERAT R CONTACT (If different than #2)
NAME(S) arr?1 ?Ls- +
PIT NAME Lry 9?'r`- yr ?`
Mailing Address 1?"`? TbT x' '3-3 1 t U-
City, St. Zip s :3 DMG NO. 76
Phone L ?n 'Z o
4. GENERAL. LOCATION OF PIT(S): COUNTY
NIL-1114
26 1/4
Sec
2'?- Twp
'7 ® N
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Range -> ? E
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5. Estimated maximum water surface to be exposed: 4-5 Acres. Number of Pits
ti. Estimated depth of pit(s) Ft. Estimated depth to groundwater Ft.
7. Estimated date to expose groundwater to complete mining
8. ATTACHMENTS: (Check which have been attached.) i
(aaled map of pit area with range, township, & section clearly identified (REQUIRED).
(b) ? Copy of the reclamation permit, if applicable.

(c) Copy of pre 1/15/89 water conservancy disl. or water user assoc. augmentation agreement, if applicable.
(d) Copy of proposed substitute water plan or augmentation plan application, if applicable.
(e) El Copy of court approved augmentation
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if a
licable
Case N
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9. Detailed descriptiop 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.
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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.)
Namerfitte (Please type or print) Signature Date

For Office Use only
Court Case No. Div. ` Co. ^ WD _ Basin MD _ Use