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<br />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. TY PE OF PERMIT <br />K7i NEW PIT(S) <br /> PIT(S) EXIST, CONSTRUCTED AFTER DEC. 31, 1980 <br />2. APPLICANT INFORMATION <br /> _ <br />NAME(S) f t e 5 - <br /> Mailing Address 4:57- .Je V f'r- <br /> City, St. Zip C P'c.. co <br /> Phone C j?:,7v ) rZ!4 <br /> <br />3. CONSULTANT/ATTORNEY/OPERATOR CONTACT (If different than #2) <br />NAME(S) 'P.5- 1c :415 t L ++ e? <br />PIT NAME <br /> Mailing Address 5e t ? a -S City, St. Zip DMG NO. i D <br /> Phone( 9-10 <br /> <br />4. GENERAL LOCATION OF PIT(S): COUNTY <br />_1/4 5W 1/4, Sec.?Twp. l ®N. ? IS., Range ` Q _ ? E. ® W. -4?=P.M. <br />5. Estimated maximum water surface to be exposed: !0 Acres. Number of Pits <br />6. Estimated depth of pit(s) Z57 Ft. Estimated depth to groundwater !5:: -- Ft. <br />7. Estimated date to expose groundwater to complete mining fZ 6ev-T- <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 />(f) ? Other --- <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 ithdrawn from the pond. <br />AILe '/1 , i 'C`.• - <br /> <br /> f? c.' <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 />pe or print) <br />Name/Title (Please t Signature Date <br />y <br />n <br />For Office Use only <br />Court Case No. Div. Co. WD Basin _ MD Use