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Form No. <br />GWS-27 <br />6!2006 <br />GRAVEL PIT WELL PERMIT APPLICATION <br />2. <br />APPLICANT INFORMATION <br />NAME(S) ,'-i of_ <br />Mailing Address ig g' iC t 0 4 0 <br />City, St. Zap 5-61,t401•/- s .i C, 0 . goYkd.' <br />Phone( 970 ) l7 2,3 A 2 <br />3. <br />4. <br />6. <br />,3. <br />1. TYPE OF PERMIT <br />COLORADO DIVISION OF WATER RESOURCES <br />DEPARTMENT OF NATURAL RESOURCES <br />(313 Sherman St., Rm 816, : ewer, Colorado 80203 <br />Phone: (303) 8664581 <br />Renew INSTRUCTIONS PRIOR TO COMPLETING FORM <br />NEW PIT(S) <br />❑ PIT(S) EXIST, CONSTRUCTED AFTER DEC. 31, 1980 <br />CONSULTANT /ATTORNEY:OPERATOR CONTACT (If different than #2) <br />NAME(SI <br />Mailing Address <br />City, St. Zip <br />Phone l <br />GENERAL LOCATION CF PIT(S): COUNTY Rio Blanco <br />SE ,/4 SE 1/4. Sec. 36 Twp, 2 <br />Estimated date to expose groundwater Now <br />For OfI1 a uJse on:y <br />NI Z,00R ooZ <br />non - crl <br />Cot.rt Casa No. <br />EVae - l4G€l<tr silfAan - Z, 63 /i4r <br />ul ur 7 <br />For Office Use only <br />5. Estimated n aximurn water surface to oe exposed: 1 Acres. Number of Pits 1 <br />Estimated aepth of pit(s) 1 4 Ft. Estimated death to groundwater 4 Ft. <br />PIT NAME WRC . Gravel Pit <br />DMG NO. <br />E N. S., Range 9 7 L� E. W. 6th P.M. <br />; to complete mining October 2008 - -� <br />ATTACHMENTS: (Check which have been attached.) <br />(a) El Scaled map of pit area with range, township, & section clearly identified (REQUIRED). <br />(b) ❑ Copy of the reclamation permit, if applicable. <br />(c) 0 Cop of pre "!15/89 water conservancy dist. cr water user assoc. augmentation agreement if applicable. (d) E Copy of proposed substitute water pan or augmentation plan application, if applicable. <br />(e) E Copy of court approved augmentation pian, if applicable. Case No. <br />(f) ❑ Other <br />9. Detailed description of any use, cther than evaporation, and method of diversion, rate of diversion, and annual amount of <br />diversion of any water withdrawn from the pond. <br />10. I (we) have read the statements made herein and know the contents thereof, and tnat they are true to my (our) <br />knowledge. [Pursuant to Section 24-4 -104 (13)(a) C.R.S., the making of false statements herein constitutes perjury <br />in the second degree and is punishable as a class 1 misdemeanor.) <br />Name,Title (Pease type or print) Signan:re <br />�ov\a1d V ik�u .4 i^a. <br />Date <br />/1 <br />1 '`, 2 z os <br />Trans Number: 3633674 <br />9/25/2008 3:22:10 PM <br />James Martin (19) <br />Div. 1y Co. WD ` Basin MD use Total Trans Amt $100.00 <br />-- -- -FRED!( <br />p.1 <br />RECEIVED <br />SEP 2 5 2008 <br />`CATER RESOURCES <br />STATE ENGINEER <br />0 A <br />Check Amount: $100.00 <br />