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STATE OF OREGON

WATER RESOURCES DEPARTMENT


RECEIPT# 117326 725 Summer St. N.E. Ste. A
INVOICE# _ _ _ _ __

I=1G-\$\
SALEM, OR 97301-4172
(503) 986-0900 I (503) 986-0904 {fax)

:~~EIVED '"°"' K.~'J :J. ie,1.ji nst"" '!.J


CASH: CH~ OTHER: (IDENTIFY)
D ~Jt)3q D _____ TMALREC'D 1$ l'YJO,{J)
I 1083 TREASURY 4170 WRD MISC CASH ACCT
0407 COPIES
OTHER: (IDENTIFY)

0243 1/S Lease 0244 Muni Water Mgmt. Plan__ 0245 Cons. Water

·4270 WRD OPERATING ACCT


MISCELLANEOUS
0407 COPY & TAPE FEES \.\b\\\ $
0410 RESEARCH FEES $
0408 MISC REVENUE: (IDENTIFY) $
TC162 DEPOSIT LIAB. (IDENTIFY) $
0240 EXTENSION OF TIME $
WATER RIGHTS: EXAM FEE RECORD FEE
0201 SURFACE WATER $ 0202 $
0203 GROUND WATER $ ,,\.\50.00 0204 $4
0205 TRANSFER $
WELL CONSTRUCTION exAMFEE LICENSE FEE
0218 WELL DRILL CONSTRUCTOR $ 0219 $
LANDOWNER'S PERMIT 0220 $

OTHER (IDENTIFY)------------------

I 0536 TREASURY 0437 WELL CONST. START FEE


0211 WELL CONST START FEE
0210 MONITORING WELLS

OTHER (IDENTIFY)------------------

I 0607 TREASURY 0467 HYDRO ACTIVITY we NUMBER


0233 POWER LICENSE FEE (FW/WRD) I I I,_$________,
0231 HYDRO LICENSE FEE (FW/WRD) I 11~$----~
HYDRO APPLICATION ~I$____~
TREASURY OTHER/ROX
FUND _ _ _ _ _ _ _ TITLE - - - - - - - -
OBJ. CODE VENDOR# _ _ _ _ _ __

DESCRIPTION - - - - - - - - - - - - - - -

RECEIPT: 117326
Distribution - White Copy - Customer, Yellow Copy • Fiscal, Blue Copy - File, Buff Copy - Fiscal
-
I '_.; - / ~tanctarct 1\pplication Co1npleteness Checklist
\li11imu111 Requircnll'nls (0.\R 1i 1JO-JI0-0040110RS 5J7All01
Thi' i, the che1.·h.li't Lhl'd h\ \\"!{[) qaff
·-'
c"" n" \ {ay.>....h,_\__\
g_~yJ _!..../ ScL'tion ___j___~
~

C(\ H.k·t i11fo: :\ppli..:ant10rgani1.1t1,rn :\amc and '.\Luling AddrL'''

SignaturL' (in inh.) nf uf! applicanh Pr thL' applicant·, autlwri1cd agent (include title or authnrity if for an
t ·gani;atinn or Cl1f!1Llratiun l.

~e' t) "" ne' 'hi I' llne' the a Pl' I"·'"" on n a 11 the Iand for the I''''l'""·d r "'J cd'
111\'11:

0 The ~1fkctL·J lando\\ ncr", !LltllL' and mailing addrc,, mu~t be li,tcd

0 :\ 'ig111.·d "tatl'llll'llt declaring the L'\i,lt.'111.:l' of t'ithcr \\ rit!L'n autlwri1ati,111 or a11 l'<hl'lllcnt permitting
acct.''~ t,1 land cro,,cd by the prupo"t'd d1k·h L·a11al or othL'r \\ \1rh. llllht h1..' ~uhmittcd.

~~:For u S\\'. \e11lir·orio11 Sourl'L' of\\ atL:r llllht ht' ind11.·atl'd


0 If thL' ,,llll"L'l' j, ,t,1rc·d \\ at·..·1. 1, tl11..· ,t,1rcd \\ ~tk'r Cll111p,111 ..'11t fi lkd llllt and dtk'' tht' applicant ll\\ n the
rL''l'l"\Uir or inc·ludL' a 11,111-t'\[lirL'd agrcenh:nt fur qored \\atl'r.> (ORS :'i.\7.-.+001
.\'OTF: :\ 111r/{1n· Hurcr ll/i/J/i,·ur1011 cu1111or hc/i!cd or rl1c 1w11c ri111e 01· u Rc1cn oir or ;\ft Rcsen 01r 1/ ir
11·i// he fi1r rlie 111·c nf rlie srorcd 11ura1111da rlu' l'ROPOSF[) R1'>tTi11ir ap11lirntio11, Erp. Sccondun 1El1.

0 If for 'tor1..·d \Lttl'r not unLkr cnntra,:t. i, th1..' 'ollrL·c authori1cd und1..·r a fk'r111i1. certificatL'. (1r dccrL't.' !
Permit or Certificat.: i~-.ucd i Y I ~ Permit tir Certificate# ____________________

11 u (;\\· Ar1il1t·urio11: \\'ell [)._•\ eloprncnt Table-. cnmpkted and/or <_1 ''ell log rcpL1rt irh:ludcd (if exi~ting)

·u~1,h
·d \\ all'r u ,~·
.- nwunt of \\,ttl'r frLlfll euch ..,ource tTl GP\!. CF·S. or Af-
Pcnnd uf the md1cated
P1 f for 'uppkmcntal irrig:,niun. prinur: acreage or underlying pcrrrnt or c'-'rttfo:dtl' number Ji,kd
1l'1iP111n und Su11p!c111e11rul /tn~a11011 < ou1111 u1 2 u1n l

~1· .u,·r \I u1.>gcmc·nt Sect' un 1I.1 '""" "" '' tlu u ,,,,. 1 "'" "' /un ""' /u ,.,, d,.,, '"' J1

~ Rc'l'llrCL' Protection Scctiun (.\'/-\ fin Gro1111r/',1 ura)


#~-11 u!I 1rw11/,mi rc\1 noi1 upp/1t'Cllim11 Prel1min,tr) pLtri-. ,md 'pcc1f1c.tt1LHh tncluJ111g dam hctght. \\tJth.
re..,t \\ 1dth .tnd -,urfxe arL'd tor each rc,en 01r
f'r,11cct , ..·heduk I If~:. ,£l'm h alr1..'dd) cumpktcJ. 1nd1cate 'c\i,tin_:I." I

1<12•.21 l l \\!
~l ppkill;.'llt:li d.tt~l 'Ii'-''-'[' l'll: ill,c'J (if llL'Cd,'d l
D h1r111 \I ( \luni ..:ip,tl t'r {)tu,i-\!uniL·ip:il I
. D Sr1in:; lk-criptil111 Shcl't !ifsL1urcl' i' a ,prin.'!I

_Vnpktcd Land-l'se Form Dr r1e'L'L'ipt .;ign...'d and d:tkd h: th<..' apprupri,tk' r11anni11g LL'pJrt!ll,'ilt L'ffi,:i.ih
~\;1:,1\ :c /le t't'rtui11 that rht' /u11,f-l 'lt'fi1rm lilfs of/ /([!1i/1 i111 o/i cd u11d of! 111·1'' flUif'llSt'd. /),Ut o( 1ic.;1w'11rt'
1

111!111

he 1·-irhi11 the r111sr 12 111011rhs

~'""I ll escri p Iion of a 11 the p "'I'""''


i'" oh ,•d " It,· cc '"" ,., i, d" crtcJ. ,. n" d. anJ lhc·d. Tl n· I c' a I
· Lk,L'riptinn i1h.:ludc.'~ a mc'tl'' anJ hL1llml.; or uthL'f gnh'lllllk'llt -.un l') ck.;i.:ripti1111 ..-\ l'11p: L'f tli,' dc'l'Ll. Lmd
,ak.; l'\1rltrai.:t or titk in.;urallL't.' pli!icy can prm iLk thi.; information. or app!i..:dnt nu: .. uhmit a l11t b11L1~ rcpl11·t
\ /,lrl·d h: a title L'L'll1[1an:. C\1pieq1(L!\ bilh arl' not a..:L'l'pt~1l1Je.

~he pr11[1tl:'l'li ,(1lll'l.'l'rs I ~(~r..:kPill') fl',tri..:tl'd Dr\\ ithdra\\ n fwm furth-.·r apprl1pri:1til 111
\DIE: Ii it i1· II ir/u/n111 II 1111der ORS 538, r/i,·11 l't'fllrn ili'f'licu1in11 ill!d fr(.\ It it i1 \\ ithJm11 I! hr orh,·1
µ+JJ .
llit'(/I' '·

(7·1 11 the u;111firnrio11011d1111c1Zufi\'(' JR 11 ill !1c il'l'ul'd C.,.kv'a.


..\-4~

\T\lier m;i> 111l1't ~llL'l.'t all the, 111irn111u111 requirL·111c11h of 0.-\R 690-310-00:'iO.
· •CT,,lo\\ n~h1p. Range. Secllllll
. B_,.,1'.ncation of 111ai11 ca11ab. ditclJL''· pipeline.; Llr tlum . :.; !if PO.-\fl'C)[) i' ouhiLIL' of l'Ol'1
;6 _,,.PtaL'l' nf lhL'. 1 •- 1.•';,
and ta\ Int ckarh identified
. E'.ffal'll 111,tp ~..:ak nut k,-, tlm1 -r· = I ,;1ik (I"= I .~20 ft. l: c\a111pk,: I"= I00 t't.. I"= 200 ft.
c:J LoL·at1011 of cucli dih'r-.inn puim. \\l'll ur d,un h) rdcrcnL·l· tu a reL·ug11i1ed puhl!L' Ltnd ~llr\L') l'l11'1L'I.
ultipk \\L'il, ;,hall h...' uniqul·I: J,1bekd, and idL'ntifil•d 011 \\L'li l()g, if l'\i,ting
{L'fl'rci1..:L' CllfllL'r t111 map
. orth llirl'L'til1n,tl S: mb\ll
:\umher uf al·rc, [ll'r 1•- 1 1 if fur irn2!ati1111. nUhL'I''.>, or a,>!riculture
;nr a 'tandarJ rc~en \1ir applil'atilln 1t1 ~ture ~: 9.2 acre feet:\~[) ha\ ing a dam height~· I() fl'l'l, m.tp
r 1tht he prepared hy a C\\'RE

~es: FLi-e F1e·c s J12_Q_ P1eT111it R.cL·t1rJ1r12 Fee;; S_~~-


J-' CFS <a S}OO S _Jc!>O_ ;\litigation Fee S -------
add'! CFS G1 S,WQ c.>A s
___ .-\F up tu 20 :\F (c3 $30c.i s Re1.: h'I.' Total
add· 1 .-\F ('.1 $I ~.1 s ~--·-- Re..: Fee Paid
add' I :puJipoa :-:u,c (:i s ----...
add' I re.; C:1 $JL~_c;~1 s--~--

L \:1111 h..'L'Tt•tal s 1Yr-o


r; \a111 s ~1:Yro
s _l~_Q_ CJ
Fee.' Paid
:\mount lh:tu111c:d

f{;,'\ie\\ed h\: ~ C:r ~-\----------~~-----~-


- ~~----
' '

Minimurn Requirements Checklist


Minimum Requirements (OAR 690-310-0040, OAR 690-310-0050 & ORS 53 7 .615)
Include this checklist with the application
Check that each of the following items is included. The application will be returned if all required items are not
included. If you have questions, please call the Water Rights Customer Service Group at (503) 986-0900.

SECTION 1: applicant information and signature


SECTION 2: property ownership
SECTION 3: well development
SECTION 4: water use
SECTION 5: water management
SECTION 6: storage of groundwater in a reservoir
SECTION 7: use of stored groundwater from the reservoir
SECTION 8: project schedule
SECTION 9: within a district
SECTION 10: remarks

Attachments:
Land Use Information Form with approval and signature (must be an original) or signed receipt
Provide the legal description of: ( 1) the property from which the water is to be diverted, (2) any property
crossed by the proposed ditch, canal or other work, and (3) any property on which the water is to be used
as depicted on the map.
Fees - Amount enclosed: $_li_QO • 00
See the Department's Fee Schedule at www.oregon.gov/owrd or call (503) 986-0900.

Provide a map and check that each of the following items is included:
Permanent quality and drawn in ink
RECEIVED BY OWRD
Even map scale not less than 4" = 1 mile (example: 1" = 400 ft, l" = 1320 ft, etc.)
North Directional Symbol
SEP 0 8 2015
Township, Range, Section, Quarter/Quarter, Tax Lots
Reference corner on map SALEM, OR
Location of each well, and/or dam if applicable, by reference to a recognized public land survey corner
(distances north/south and east/west). Each well must be identified by a unique name and/or number.
Indicate the area of use by Quarter/Quarter and tax lot clearly identified
Number of acres per Quarter/Quarter and hatching to indicate area of use if for primary irrigation,
supplemental irrigation, or nursery
.
0. Location of main canals, ditches, pipelines or flumes (if well is outside of the area of use)
D Other~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Revised 2/1/2012 Ground W ater/2 WR

6-101J r-

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