2011-12-07_REVISION - M1986015 ‎(8)‎

• Permit No: M1986015
• IBM Index Class Name: REVISION
• Doc Date: 12/7/2011
• Doc Name: Adequacy Response
• From: Tuttle & Associates
• To: DRMS
• Type & Sequence: AM4
• Email Name: TC1
• Media Type: D
• Archive: No

•
t le Form " •
No.
GWSS -11
tig
STATE OF COLORADO
OFFICE OF THE STATE ENGINEER
818 Centennial Bldg., 1313 Sherman St., Denver, CO 80203
3) 866 -3581 Fax [phone]
_ t r
4 -
NGE IN OWNERSHIP /ADDRESS
RECTION OF THE WELL LOCATION
DEC
Na a address an • . i . t e of the ' : on claimin
NAME(S) 6.
Mailing Mailing Address
This Vino is made pursuant to C.R.S. 37 -90 -143.
County PUE$ /. 0
WELL LOCATION
.3
(Address)
-4"
State Engineer B y
Signature s) of the new owner.
For Off= Use Only
For Office Use Only
ACC 7fE A� S
At :s) /( tviA &„
Date
RECEIVED
JAN 06 2004
WATER RESOURCES
STATE t ENGINEER
rep o (C23 S S
If your well has an absolute water right, decreed
by the court and the well is not registered with the
State Engineer, enter the Water Court Case
Number / Civil Action Number and well number
as decreed.
City, St. Zip _Lo O 8`1
tl SEE A T :War
Phone ( IT 1
q, — Ortiek tove es
This form is filed by the named individual/entity claiming that they are the owner of the well permitted as referenced above.
Owner's Well Designation 2135 7
PUESt fi co $1001
(Cit • (State) (Zip)
IV W1/4 of the Na 114, Sec. 3, Twp. _10-- N. or g S., Range CU 0 E. orti3 W., 617/ P.M.
Distance from Section Lines Ft. From X N. or 0 S., 1 got Ft. From 0 E. or OW. Line.
fm
Lot Block , Filing /Unit
Subdivision Name
The above listed owner(s) say(s) that he, she (they) own the well described herein., The existing record is being
amended for the following reasons: W Change In name of owner 14 Change in mailing address
0 Correction of location for exempt wells permitted prior to May 8, 1972 and non - exempt wells permitted before
May 17, 1965. Please see the reverse side for further information regarding correction of the well location.
(we) claim and say that I (we) (are) the owner(s) of the well described above and that the commencement of
extraction of ground water from this well, lawfully made under the well permit, occurred on the date indicated, and
that the statements made herein are true to my (our) knowledge.
Please print the Signer's Name & Title
avoviz
i-Eve Sj ,arMApt/
It is the responsibility of the new owner of this well to complete and sign the form. Signatures of agents are acceptable if an
original Letter of agency signed by the owner is attached to the form upon its receipt.
I2 -V2Oi3
e tN OWNERSHIP
Z f7 -0 1
Date