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Pur <br />TyE <br />Pov <br />Pur <br />Mo <br />Dat <br />Pun <br />Rer <br />WEl <br />Dat <br />Stagy <br />Len <br />Sus' <br />Pun <br />Rer <br />CONTRACTORS STATEMENT <br />The undersigned, being duly sworn upon oath, deposes and says that he is the contractor of the well or <br />pump installation described hereon; that he has read the statement made hereon; knows the content <br />thereof, and that the same is true of his own knowledge. <br />Signature <br />State of Colorado, County of Hu~`fano <br />Subscribed and sworn to before me this 14 day of <br />tray <br />License No. T <br />SS <br />1973 <br />My Commission expires: December 8 ~y74 <br />Notary Public r'ti'"^-~-M - u-e~ ~e~~o~ eL <br />8 <br /> <br /> <br /> <br />FORM TO BE MADE OUT IN OUA DR UPLICATE: WHITE FORM must be an original copy on both sides and signed. <br />WHITE AND GREEN copies must be filed with the State Engineer. PINK GOPV is sot the Ow~ne. and YELLOW COPY is for tha Driller <br />