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SALEM, OR 97301-4172
(503) 986-0900 I (503) 986-0904 {fax)
0243 1/S Lease 0244 Muni Water Mgmt. Plan__ 0245 Cons. Water
OTHER (IDENTIFY)------------------
OTHER (IDENTIFY)------------------
DESCRIPTION - - - - - - - - - - - - - - -
RECEIPT: 117326
Distribution - White Copy - Customer, Yellow Copy • Fiscal, Blue Copy - File, Buff Copy - Fiscal
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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
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c"" n" \ {ay.>....h,_\__\
g_~yJ _!..../ ScL'tion ___j___~
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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.
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
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 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
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llit'(/I' '·
\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
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)
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