HomeMy WebLinkAbout980153.tiff `NM NO STATE OF COLORA ) --- . «,,a. Jae nn '
OFFICE OF THE STAR ENGINEER RECE)v:n a(L,
ate Cenueeaat Bldg_ 1313 Sharman St.Denver,Colorado 00203
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HF0OR 7() COMPLETING FORM, SEE INSTRUCTIONS ON REVERSE SIDE
CHANGE IN OWNERSHIF'LADDRESS / LOCATION WAfrz•iSTAT a :, ems'
WELL PERMIT, LMEST'OCK TANK OR EROSION CONTROL DAM COLO
NEW DWNER
NAM
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Mailing Address 33 soO W C.R 1 lo
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CM. St. Zlp 'KEE/N� E'.��1BU^RG ,n?Cc, �0�43 r. 0\' ''t
phone 303) '72 z- 46043 , ��J
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2 THLCL GRANDE IS FOR ONE OF THE FOLLOWING: r. 4 - ..
[TH WELL PERMIT NUMBER c5 15 a a . C>o n'u:S it c v J i
1 UVESTOCK WATER TANK NUMBER
EROSION CONTROL DAM NUMBER
3 WEU. LOCATION: COUNTY 1/0 Et."- LD OWNER'S WELL DES'GNA' C '_k z.Ne377C.
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\' Xl,' (CM) -1(Stale) OP)
N(: 114 S tam NU.) 1/4, Sec.3y. Twp. *a L N. «❑S., Range 3 f k e. j' ,+ h P M
Distances from Section Lines 2 OO Ft. from El N. or E3 Une, , O `• , ,E ,r r ``W Line.
Subdivision . Lot Block f r'irg (Unit
4 LIVESTOCK TANK OR EROSION CONTROL DAM LOCATION COUNTY
114. Sec. Twp. ElN. o.IDS., Range 7 E o- Li W P M ___
5 The above listed owner(s) say(s) that he (they) own the structure described herein.
The existing record Is being amended for the following reason(s):
�Cy
6CJ Change In name of owner. ❑ Change in mailing address. . _1 kjurrearon of vocation.
6 (wi.) have read the statements made retain, knov:the contents thereof, and state that rev P.'- " .-
to my (our) knowledge
Pwsuant to SeetIon 244104 (13)(a) O.R.S., the making of false statements herein construteE ...
the second degree end Is punishable es a class 1 misdemeanor.)
~ Name/Title (Please typo or print) S atu e, _ Date
i)R$RRr4 Cr .' QPe �sNel �� is / 7
it FOR OFFICE USE ONLY
ACCErTrF.D AS A CH '' r`r rat(IWNFR CUM
AND/OR MAILING AUurnt.a3.
980153
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1 „ d Z AID - /� Gl J t F v n EXHIBIT
an Engineer By/ _ Do's
foul Case No On' I/ Co. (r z,"‘-n, WD / Basin d-- MD__.. '
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