Free DBB-012b, Application for Change of Permit Location of a Well - Colorado

DBB-012(B) (6/2006)

APPLICATION FOR CHANGE OF PERMIT LOCATION OF A WELL 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 application 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. ______________________ and I hereby apply to change the permitted location of this well to the original and historic well site as constructed in the field. The permitted location of the well is as follows: ft. from the __________ section line and
(north or south)

ft. from the __________ section line,
(east or west)

_______1/4 of the _______1/4 of Section _______, Township _______ N/S, Range ________ W.

The original and historic field location of the well as constructed is as follows: ft. from the __________ section line and
(north or south)

ft. from the __________ section line,
(east or west)

_______1/4 of the _______1/4 of Section _______, Township _______ N/S, Range ________ W. Enclosed herewith is the nonrefundable application fee of $100. I understand that this request will be published in the local newspaper(s) as may be required by law and that I will pay the actual publication cost to the Commission when the same is billed to me. Signed and dated this ____________ day of __________________________, 20____________.

Signature of Applicant: __________________________________________________________ Applicant's Name: Address: City, State & Zip: Telephone No.: __________________________________________________________
(Please Print)

__________________________________________________________ __________________________________________________________ __________________________________________________________ FOR OFFICE USE ONLY Basin MD

Div.

Co.

WD

Use

Receipt No._______