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Pur <br />Ty{ <br />Pov <br />Pur <br />Mo <br />Dat <br />Pun <br />Rer <br />WEI <br />Dat <br />Staff <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 License No. ~~ <br />State of Colorado, County of ttt+nrfan0 SS <br />Subscribed and sworn to before me this 14 day of I~ay , 1973 <br />My Commission expires: December 8 1g 74 <br />- -~ <br />Notary Public h^-w-++~-«-~- ~- r "~ <br />rguer>,te o ei~ <br />.~ <br />'--~ <br />• <br />FORM TO BE MADE OVT IN OUA DR UPLICATE: WHITE FORM must 6e an original copy an bo[h sides and signed. <br />WHITE AND GREEN copies must be filed with the State Engineer. PINK COPY is for the Owner and FELLOW COPY is for the Driller <br />