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'" *RJ -5 -73 <br />Application must <br />be complete where <br />applicable. Type or <br />print in BLACK <br />INK. No overstrikes <br />or erasures unless <br />initialed. Proper fee <br />must be submitted <br />with the application. <br />COLORADO DIVISION OF WATER RESOURCES <br />300 Columbine Bldg., 1845 Sherman St., Denver, Colorado 80203 <br />PERMIT APPLICATION FORM <br />1 ) A PERMIT TO USE GROUNDWATER <br />( )<) A PERMIT TO CONSTRUCT A WELL <br />FOR: ()<) A PERMIT TO INSTALL A PUMP <br />( ) REPLACEMENT FOR NO. <br />( ) OTHER <br />APPLICANT - mailing address <br />NAME Arck e.42m *w <br />STREET /3//4 <br />CITY 1 &Ge <br />(state) (Zip) <br />TELEPHONE NO. <br />(2) LOCATION OF PROPOSED WELL <br />County.. P4Aa114 ' u <br />of the IV Lt.) '/4, Section _ <br />Twp. _.1.3_— S, Ring. _1 cam _ A✓ 0P <br />(3) WATER USE AND WELL DATA <br />Proposed maximum pumping rate (gpm) 3 <br />Average annual amount of ground water L <br />to be appropriated (acre-feet): <br />Number of acres to be irrigated: <br />Proposed total depth (feetl : 400K /,6-0 <br />Aquifer ground 'wafer i° to be obtained from: <br />Owner's well designation <br />GROUND WATER TO BE USED FOR <br />( t4- HOUSEHOLD USE ONLY <br />( 1 DOMESTIC (1) <br />( 1 LIVESTOCK (2) <br />( ) COMMERCIAL (4) <br />) OTHER (9) <br />no irrigation (0) <br />( ) INDUSTRIAL (5) <br />( ) IRRIGATION (6) <br />( ) MUNICIPAL (8) <br />(4) DRILLER <br />TIMBERLINE DRILLING <br />Name Star Route <br />Street Flnriss�int, Colorado 80816 <br />City <br />748 -3243 ( state}...._ 57-5 (zlp) <br />Telephone No. Lic. No. <br />?^1JN <br />FOR OFFICE USE ONLY: DO NOT WRITE IN THIS COLUMN <br />Receipt No. <br />Basin Dist, <br />CONDITIONS OF APPROVAL <br />This well shall be used in such a way as to cause <br />no material injury to existing water rights. The <br />issuance of the permit does not assure 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 />APPROVED FOR HOUSEHOLD USE ONLY, FOR ONE <br />(1) SINGLE FAMILY DWELLING AND NOT TO BE <br />USED FOR IRRIGATION. THE RETURN FLOW FROM <br />THE USE OF THIS WELL MUST BE RETURNED TO <br />THE SAME STREA114 SYSTP.M IN WHICH THE WELL <br />IS LOCATED. <br />S , —I . 4,I `K _, f <br />APPLICATION APPROVED <br />I.D. W.D. -_ q.3.- _ COUNTY _ <br />PERMIT NUMBER 74900 <br />DATE ISSUED JUN 14 197A <br />iiim 1 ,1 107A <br />h. <br />