JDF 241 W R 5 - 1 5 APPLICATION FOR SIMPLE CHANGE IN A SURFACE POINT OF DIVERSION Page 1 of 5 District Court, Water Division , Colorado Court Address : CONCERNING THE APPLICATION FOR WATER RIGHTS OF Applicant: In the River or its Tributaries In COUNTY COURT USE ONLY Attorney or Party Without Attorney (Name and Address): Phone Number: E - mail: FAX Number: Atty. Reg. #: Case Number: Division: Courtroom: APPLICATION FOR SIMPLE CHANGE IN SURFACE POINT OF DIVERSION PURSUANT TO 247 37 - 92 - 305(3.5) , C.R.S. A simple change in a surface point of diversion means a change in the point of diversion from a decreed surface diversion point to a new surface diversion point that is not combined with and does not include any other type of change of water right and for which there is no intervening surface diversion point or inflow betwee n the new point of diversion and the diversion point from which a change is being made. It does not include a change in point of diversion from below or within a stream reach for which there is an intervening surface diversion point or inflow or decreed i n - stream flow right to an upstream location within or above that reach. 247 37 - 92 - 305 ( 3. 5) (a)(II) , C .R.S. decreed surface water right, point of replacement or point of diversion by exchange that is part of an existing decreed exchange, well or well f ield that is decreed to operate as a surface diversion, or point of inflow from a tributary surface stream. 247 37 - 92 - 305 ( 3. 5) (a)(I) , C.R.S. An application for a simple change in a surface point of diversion is subject to all the provisions of Article 92, including sections 37 - 92 - 302 to 37 - 92 - 305, except as specifically modified by 247 37 - 92 - 305 ( 3. 5), C.R.S. the location for the decreed surface point of diversion and the new surface point of diversion . For dec reed surface point of diversion , use the location from the most recent decree that adjudicated the location . UTM coordinates ( for example from a GPS device ), or measured distances in the field from known section lines are acceptable for the new surface point of diversion . The Division Engineer, the Water Referee, or the Water Judge, may order the applicant to confirm the location of any structure with UTM coordinates, a survey, or other method. 1. Name, mailing address , email addre ss and telephone number of applicant(s) (if there are multiple applicants, and the space provided is not adequate to list all of the applicants, the names, addresses, telephone numbers and available email addresses must be provided as an attachment) : Name of Applicant Mailing Address Email address Telep hone Number 2. Decreed water right for which change is sought: American LegalNet, Inc. www.FormsWorkFlow.com JDF 241 W R 5 - 1 5 APPLICATION FOR SIMPLE CHANGE IN A SURFACE POINT OF DIVERSION Page 2 of 5 A. Name of structure: B. Date of original and all relevant subsequent decrees: Case No: Court: C. Legal description of structure as described in most recent decree that adjudicated the location : Provide a verbatim legal description from the most recent decree that adjudicated the location . M ark the location of the structure on a USGS topographic map and attach to thi s application a legible 8 275 x 11 inch copy of th e applicable portion of the map . D. Decreed s ource of water : E. Appropriation Date: F. Total a mount decreed to structure in gallons per minute (gpm) or cubic feet per second (cfs) : Conditional Absolute G. Decreed use or uses: H. Amount of water that a pplicant intends to change: Conditional Absolute 3. Detai led description of p roposed change in a surface point of diversion : A. C omplete statement of change, including a description of how the change meets the definition of a simple change in a surface point of diversion. T he applicant bears the burden to prove that the simple change in a surface point of diversion will not : (I) result in diversion of a greater flow rate or amount of water than has been decreed to the water right and, without requantifying the water right, is physically and legally available at t he diversion point from which a change is being made ; or (II) injuriously affect the owner of or persons entitled to use water under a vested water right or decreed conditional water right. The applicant is encouraged to provide evidence to support such i nformation with this application. B. Location of the new surface point of diversion: L ocation information in UTM format (Preferred): UTM Zone must be 12 or 13; Units must be Meters; Datum must be NAD83 ; and Units must be set to true North. Include the source of the UTM coordinates , for example : GPS device , a GIS system such as DWR AquaMap or CDSS MapViewer; scaled from USGS topo graphic map ; or other source. In areas having generally recognized street addresses, also include street address, and if applicable, the lot, block, and subdivision . A ttach a legible 8 275 x 11 inch map to this application illustrating location of the new point of diversion structure . American LegalNet, Inc. www.FormsWorkFlow.com JDF 241 W R 5 - 1 5 APPLICATION FOR SIMPLE CHANGE IN A SURFACE POINT OF DIVERSION Page 3 of 5 UTM coordinates Easting Northing Zone 12 Zone 13 Street Address: Subdivision: Lot Block Source of UTMs ( for example , hand - held Garmin GPS): Accuracy of location displayed on GPS device ( for example, accurate to within 200 feet): Legal Description Using the Public Land Survey System (PLSS) ( Optional ; Please include both UTM and PLSS descriptions if known ) : I nclude perpendicular distances from section lines, and indicate 274 274, section number, township, range , meridian and county ; mark the location of the structure on a USGS topographic map and attach to this application a legible 8 275 x 11 inch copy of the applicable portion of the map. In areas where section lines have not been established, a bearing and distance to an established government monument is acceptable. Include the source of PLSS information , for example: GIS system such as DWR AquaMap or CDSS MapViewer; field survey ; sc aled from a USGS topographic map; or other source. In areas having generally recognized street addresses, also include street address, and if applicable, the lot, block, and subdivision . Legal Description: County 1/4 of the 1/4 Section Township N or S Range E or W Principal Meridian Distance from section lines (not from property lines) Feet from N S and Feet from E W Source of PLSS information: Street Address: Subdivision: Lot Block 4. Name(s) and address(es) of owner(s) or reputed owners of the land upon which any new diversion structure, or modification to any existing diversion structu re is or will be constructed . The applicant must notify these persons that the applicant is applying for this water right, and certify to the Court that the applicant has done so. Name of Owner Mailing Address Signature of Applicant(s) (if self - represented) or Attorney Date American LegalNet, Inc. www.FormsWorkFlow.com JDF 241 W R 5 - 1 5 APPLICATION FOR SIMPLE CHANGE IN A SURFACE POINT OF DIVERSION Page 4 of 5 VERIFICATION AND ACKNOWLEDGMENT OF APPLICANT OR OTHER PERSON HAVING KNOWLEDGE OF THE FACTS STATED IN THIS APPLICATION I b eing first duly sworn, hereby state that I have read this Application, that I have personal knowledge of the facts stated and, that I verify its contents to the best of my knowledge, information, and belief. Signature Date The foregoing instrument was acknowledged before me in the County of , State of Colorado, this day of , 20, by the person whose signature appears above. My Commission Expires: Notary Public/Deputy Clerk The person signing this verification is: Applicant Engineer Other (describe) Verifications of other persons having knowledge of the facts may be attached to this application. American LegalNet, Inc. www.FormsWorkFlow.com JDF 241 W R 5 - 1 5 APPLICATION FOR SIMPLE CHANGE IN A SURFACE POINT OF DIVERSION Page 5 of 5 District Court, Water Division , Colorado Court Address : CONCERNING THE APPLICATION FOR WATER RIGHTS OF Applicant: In the River or its Tributaries In COUNTY COURT USE ONLY Attorney or Party Without Attorney (Name and Addr