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Pur <br />i yl <br />?Oy <br />~Ur <br />Mo <br />Dat <br />Pur <br />Rer <br />wEl <br />Dat <br />Sta~ <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 kn~wJefj,ge. <br />Signature ~/ G'~7'~~ License No. <br />State of Colorado, County of Haeffano SS <br />Subscribed and sworn to before me this 18 day of June 19 73 <br />My Commission expires: ~'8 , 19 74 . <br />Notary Public ~-u- -r- Y ~ ~ ~ • L <br />Margu rite J. Ha e <br />• <br />FORM TO BE MADE OUT IN OUADR UPLICATE~ WHITE FORM must be an onginal copy on both sides and signed. <br />WHITE AND GREEN copies must be filed with the State Engineer. PINK COPY is far the Owner and YELLOW COPY is for the Driller <br />