Free DBB-011, Waiver of Claim to Injury - Colorado

DBB-011 (03/2004)

WAIVER OF CLAIM TO INJURY COLORADO GROUND WATER COMMISSION Room 818 Centennial Building, 1313 Sherman Street Denver, CO 80203

Application must be complete where applicable. Type or print in BLACK INK. No overstrikes or erasures unless initialed.

NOTE: This form can only be used for wells located within a Designated Ground Water Basin. I, , affirm that I am the present owner of the well with

Permit No. ______________________ located in the _________1/4 of the ________1/4 of Section ________, Township ___________ North/South, Range __________ West of the 6th P.M. As owner of this well, I hereby waive all claim to injury which may arise from the proximity of the well involved in the (check appropriate box): new permit application with Receipt No. _____________________________ replacement application for Permit No. ______________________________ change of water right application for Permit No. _______________________ other (describe) ________________________________________________ applied for by West of the 6th P.M. , which is located in the _________1/4 of the

________1/4 of Section ________, Township ___________ North/South, Range __________

Signed and dated this ____________ day of __________________________, 20____________.

Signature of Well Owner: ________________________________________________________ Well Owner Name: Address: City, State & Zip: Telephone No. : __________________________________________________________
(Please Print)

__________________________________________________________ __________________________________________________________ __________________________________________________________