Free GWS-67, APPLICATION TO CHANGE A DETERMINATION OF WATER RIGHT PURSUANT TO SECTION 37-90-111(1)(g), C.R.S. - Colorado

COLORADO GROUND WATER COMMISSION DIVISION OF WATER RESOURCES DEPARTMENT OF NATURAL RESOURCES 1313 Sherman St, Room 818, Denver, CO 80203

APPLICATION TO CHANGE A DETERMINATION OF WATER RIGHT PURSUANT TO SECTION 37-90-111(1)(g), C.R.S.
NOTE: This application can only be used to apply to change the conditions of a Determination of Water Right approved by the Ground Water Commission pursuant to Section 37-90-107(7), C.R.S, for the Dawson, Denver, Arapahoe or Laramie-Fox Hills aquifers. This form must be completed, signed, dated and submitted to the Commission with a non-refundable $100 filing fee. Type or print in black ink.

1. APPLICANT INFORMATION ­ applicant must control the subject water right
Name of Applicant

Applicant Mailing Address

Applicant Telephone Number (include area code)

2. DETERMINATION NUMBER -

3. DESCRIPTION OF PROPOSED CHANGE ­ provide a complete description of the proposed change(s) in the following spaces - CHANGE USE OF GROUND WATER ­ describe all proposed beneficial uses

- CHANGE PLACE OF USE ­ provide a complete legal description of the proposed place of use ­ if the legal description is too
lengthy for this space, provide the description as an attachment to the application

- DECREASE OR EXCLUDE ALLOWED ANNUAL AMOUNT OF ALLOCATION ­ describe proposed change

- OTHER CHANGES IN THE CONDITIONS OF THE DETERMINATION ­ describe proposed change(s)

4. SIGNATURE OF APPLICANT ­ must be original signature - I have read the statements herein, know the contents thereof, and
state that they are true to my knowledge.

Signature - print name and title

Date

FOR OFFICE USE ONLY

DIV_______ CO_______WD______BASIN________MD_______
Form GWS-67(6/2006)