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WRJ~S72 <br />Application must <br />tie complete where <br />.pplicable. Type or <br />print in BLACK <br />~K. Nooverstrikes <br />erasures unless <br />initialed. <br />COLORADO DIVISION OF WATER RESOURCES ~ <br />' 101 Columbine Bldg., 1845 Sherman St., Denver, Colorado 80203 <br />PERMIT APPLICATION FORM <br />A PERMIT TO USE GROUND WATER <br />A PERMIT TO CONSTRUCT A WELL <br />FOR: ~ A PERMIT TO INSTALL A PUMP <br />)REPLACEMENT FOR N0. <br />(OTHER <br />ng <br />NAME <br />FOR OFFICE USE ONLY: DO NOT WRITE IN THIS COLUMN <br />STREET .~ o ~ /~ ~Lr /7°-? 6 (` <br />CITYS'LJ,L~P,7~E' E9ffJS ~~77 <br />State) (tip) <br />TELEPHONE N0. 3 ~ (o _ ~ 7f - /~ 6 <br />(2) LOCATION OF PROPOSED WELL <br />County ~~ F, ~ 77 r '77 a7, 5 <br />.5 w % of the Jy E %, Section s~ <br />Twp. ~_ ~ciT~Rng. ~- '7/1d7~- ~ ~~ P.M. <br />(3) WATER USE AND WELL DATA <br />~oposed maximum pumping rate (gpm) ~~ G P~ <br />erage annual amount of ground water / <br />to be appropriated (acre-feet): <br />Number of acres to be irrigated: //O .f/ e_ <br />Proposed total depth (feet): ~0 <br />Aquifer ground water is to be obtained from: <br />ST,rr~ ~~/l~9ii~ ~; ~ / <br />Owner's well designation <br />GROUND WATER TO BE USED FOR: <br />VG1 HOUSEHOLD USE ONLY <br />1 )DOMESTIC 111 <br />( )LIVESTOCK 121 <br />)COMMERCIAL 141 <br />no irrigation 101 <br />( )INDUSTRIAL 15) <br />( I IRRIGATION (61 <br />1 MUNICIPAL (81 <br />1 1 OTHER 191 <br />(4) DRILLER <br />~ueet r ~ FJ m ~ ~~ <br />Telephone No. SYIv-~~~~ Lic. No. ~~ <br />Receipt No. !-~ o .2 ~n / _ <br />Basin Dist. <br />CONDITIONS OF APPROVAL <br />This well shall be used in such a way as to cause <br />no material injury to existing water rights. The <br />issuance of the permit does not assure the applicant <br />that no injury will occur to another vested water <br />right or preclude another owner of a vested water <br />right from seeking relief in a civil court action. <br />Approved for household use onty, far one (1) single ramlty dwelling end not to <br />be used far irrigation. The return flow Irom the use of this well must be <br />rtturned to the same stream system In which the we0 I5 to®ted, <br />V(JCt` =17 <br />F~ <br />~' U~,' i~ <br />N~.' <br />;,;~~ <br />3EC ~YY~~3 <br />APPLICATION APPROVED <br />6~1E~ <br />PERMIT NUMBER <br />DATE ISSUED .fAH ~+ 3 <br />EXPIRATION DATE JAN 23 975 <br />~.. <br />N ER) <br />BY <br />I.D. <br />COUNTY <br />