Application By Public Agency To Register Water Use For Road And Highway Maintenance, Contruction And Reconstruction Form - State Of Oregon Water Resources Department
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1
2Register No. RW-____________________
STATE OF OREGON
WATER RESOURCES DEPARTMENT
APPLICATION BY PUBLIC AGENCY TO REGISTER WATER USE FOR
Page |
ROAD AND HIGHWAY MAINTENANCE, CONTRUCTION AND
1
RECONSTRUCTION
Applicant: _______________________________________________________________________
(County, City, Town or Public Agency)
Name of Officer or Authorized Agent: _________________________________________________
Address: ________________________________________________________________________
_______________________________________________________________________________
City
State
Zip
Phone Number
________________________ makes application to register the use of the following described waters for
Road or Highway Maintenance or Construction.
1. Indicate the source of water for the maintenance or construction project:
_________ Groundwater, (attach copy of well log or description of the well)
_________ Surface water. If surface water, the source is ________________________
tributary to ______________________________________________________________
2. Provide the permit or certificate number if water is obtained from a well or conveyance or storage
facility that has a perfected or certificated water right:
Permit No. ____________________ or Certificate No. ___________________
3. Include written authorization from the owner of the right that allows use of water from the well or
conveyance or storage facility.
4. Indicate the maximum amount of water to be used during the calendar year:
____________ Gallons, or ______________ Acre-feet
5. Indicate the maximum amount of water to be used during any 24-hour period:
____________ Gallons, or ______________ Acre-feet
(Note: The amount of water used shall not exceed 50,000 gallons from a single source during any 24-
hour period).
6. Submit a fee in the amount of $340 with this application.
7. Provide 4 maps indicating the location(s) of the point(s) of diversion with this application. Maps may be
either a county road map or a Department basin map.
8. Provide a ODFW small pump screen self-certification form.
9. Signature: ____________________________________________________________________
Title: ________________________________
Date: ______________________________
Last Updated 06/29/2016 - MA
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