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<br />wR~.sTZ COLORADO DIVISION OF WATER RESOURCES p[/~ <br /> 101 Columbine Bldg.. 1645 Sherman St., Denver, Colorado 80204 CI,rE'VED <br />` , <br />PERMIT APPLICATION FORM APR 1 <br /> <br />Application must ~ <br />6 <br />3 <br />>e complete where A PERMIT TO USE GROUND WATER <br />q Rt <br />si <br />plicable. Type or sofrxge <br />DQ A PERMIT TO CONSTRUCT A WELL <br />~r <br />~int in ~ BLACK FOR: DQA PERMIT TO INSTALL A PUMP COtO tNEfa <br />I N K. N o overstri kes <br />or erasures unless ( )REPLACEMENT FOR NO. <br />initialed. <br />1 1 OTHER <br />mail <br />NAME /~'G~L ,~~^. IItfLJ.~~7_ <br />STREET 9/J ~ ~<~~ dh~ AF <br />CITY///~e.s7G/) . ~~O 6.2 <br />(CState) D IZiDI <br />TELEPHONE N0. 3/~3 0 ~~ -~a {O <br />(2) LOCATION OF PROPOSED WELL <br />County LRS ~h~m4 5 <br />SW '/. of the NE '/., Section ~~ <br /> <br />13). WATER USE AND WELL DATA <br />~oposed maximum pumping rate lgpml /dam <br />Average annual amount of ground water / <br />to be appropriated (acre-feet): <br />Number of acres to be irrigated: /1/Oi!/ L°. <br />Proposed total depth (feed: O ~ <br />Aquifer ground water is to be obtained from: <br />tSTo,a/~ wd//~/ ~//l.~vi~~ <br />Owner's well designation Vat /r/ E Z <br />GROUND WATER TO 8E USED FOR: <br />Qr(HOUSEHOLD USE ONLY <br />1 1 DOMESTIC i11 <br />I 1 LIVESTOCK 121 <br />4 1 COMMERCIAL (4) <br />( 1 OTHER 191 <br />no irrigation (01 <br />( 1 INDUSTRIAL (5) <br />( )IRRIGATION I61 <br />( 1 MUNICIPAL (81 <br />14) DRILLER <br />'ame c <+ <br />~eet ~I'" ~ / /at/O .L~ ~ Q ~j <br />city /!-///~/ a ~d~. ~i~~ • />/D~a'/ <br />p (State( ~/IZ~p) <br />Telephone No. ol-~~-~/~~ Lic. No. ~/ - <br />RECE1VEp~J" <br />AoR 0 ~ `-' <br />6 73 <br />S~a~e .vq.:,:~. <br />cct;.. <br />FOR OFFICE USE ONLY: DO NOT WRITE IN THIS COLUMN <br />Receipt No. y~~f-3~~ l <br />Basin <br />Dist. <br />CONDITIONS OF APPROVAL <br />This well shall be used in wch a way as to cause <br />no material injury to existing water rights. The <br />issuance of the permit does not aswre 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 />ADDrosed for household use only, for one (1) single famlty dwe0ng End Int m <br />tq usW for inigatian. The return flow from the used this web INBt bs <br />xWrued tD the same sUeem rystem In which Ne well Is bufad, <br />APPLICATION APPROVED <br />PERMIT NUMBER 6685 <br />DATE ISSUED MAY Z 1913 <br />EXPIRATION DATE <br />c_~.~ <br />sii~Gl <br />BY C ~~ ~q <br />I.D. ~ ' ~ / COUNTY 3 L+ <br />