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EXHIBIT C (Page 1 of 2) <br />APPLICATION FOR PARTICIPATING DIVERSIONS <br />UPPER SOUTH PLATTE BLANKET AUGMENTATION PLAN <br />Case No. 02CW389 <br />1. Applicant name, address, phone: <br />2. Location of water use: <br />3. GPS coordinates of well (if available): <br />4. General description of water use: <br />5. Square -feet of lawn and /or garden irrigation: <br />6. Approximate distance of lawn to nearest flowing stream: <br />7. Name of nearest flowing stream:: <br />8. Number of single family homes: <br />9. Type of wastewater treatment: <br />(septic tank and (each field, evapotranspiration system, or sewer line to wastewater plant) <br />Note: Evapotranspiration wastewater systems will require the replacement of 100% of the water delivered <br />to the system. <br />1 0. Other type of development (describe, and commercial users please fill out Attachment A): <br />11 . Number of large domestic animals (e.g. horses): <br />12. Surface square -feet of ponds: <br />(District use only below this line) <br />A. is location on a stream with a CWCB instream flow water right or with a potential water <br />rights dry-up location? Describe: <br />B. Consumptive use for lawn and /or garden irrigation: <br />C. ZoneA,BorC ?: <br />C. Consumptive use for single family homes: <br />D. Consumptive use for other type of development: <br />E. Consumptive use for large domestic animals: <br />F. Consumptive use for ponds: <br />G. Irrigation Season depletion (May - September): <br />!. Non - irrigation Season depletion (October -April): <br />J. Total annual depletion: (add G & H] <br />K. Including this application, the remaining' amount of replacement water is: <br />R: 1160011605 \1605.00 \ DOCUMENTS \APPU CATION FORM.doc <br />AF <br />AF <br />AF <br />AF <br />AF <br />AF <br />AF <br />AF <br />EXHIBIT <br />