Form 600 - Application For Beneficial Water Use Permit

Name of Contact ___________________________________________________________ Title ____________________________________

Address ___________________________________________________________________________________________________________

City/State/Zip ______________________________________________________________ Phone __________________________________

E-mail address _____________________________________________________________

15. AFFIDAVIT

I affirm that statements appearing here are to the best of my knowledge true and correct. I also affirm I have possessory interest, or

the written consent of the person with the possessory interest, in the property where the water is to be put to beneficial use and if

applicable, exclusive property rights in the groundwater development or the written consent of the person with those rights.

Applicant's Signature

___________________________________________________ Date ___________________________

Subscribed and sworn before me this _______________ day of _____________________________________________________

Notary's Signature ___________________________________________

Notary for the State of ________________________________________

Residing at _________________________________________________

My commission expires _______________________________________

WATER RESOURCES REGIONAL OFFICES

Billings

Havre

Lewistown

Airport Industrial Park

1371 Rimtop Drive

210 6th Avenue

613 NE Main Street, Suite E

Billings, MT 59105-1978

P .O. Box 1828

Lewistown, MT 59457-2020

Phone: 406-247-4415

Havre, MT 59501-1828

Phone: 406-538-7459

Fax: 406-247-4416

Phone: 406-265-5516

Fax: 406-538-7089

Serving: Big Horn, Carbon, Carter

Fax: 406-265-2225

Serving: Cascade, Fergus, Golden

Custer, Fallon, Powder River, Prairie,

Serving: Blaine, Chouteau,

Valley, Judith Basin, Meagher,

Rosebud, Stillwater, Sweet Grass,

Glacier, Hill, Liberty, Pondera,

Musselshell, Petroleum, and

Treasure, and Yellowstone Counties

Teton, and Toole Counties

Wheatland Counties

Bozeman

Helena

Missoula

151 Evergreen Drive, Suite C

21 North Last Chance Gulch

Town and Country Shopping Center

Bozeman, MT 59715

P .O. Box 201601

1610 South 3rd Street West, Suite 103

Phone: 406-586-3136

Helena, MT 59620-1601

P .O. Box 5004

Fax: 406-587-9726

Phone: 406-449-0944

Missoula, MT 59806-5004

Serving: Gallatin, Madison, and

Fax: 406-442-9315

Phone: 406-721-4284

Park Counties

Serving: Beaverhead, Broadwater,

Fax: 406-542-1496

Deer Lodge, Jefferson, Lewis and

Serving: Granite, Mineral,

Glasgow

Clark, Powell, and Silver Bow Counties

Missoula, and Ravalli Counties

222 6th Street South

P .O. Box 1269

Kalispell

For Mailing, Use Post Office Box Number.

Glasgow, MT 59230-1269

109 Cooperative Way, Suite 110

Phone: 406-228-2561

Kalispell, MT 59901-2387

Fax: 406-228-8706

Phone: 406-752-2288

Serving: Daniels, Dawson, Garfield,

Fax: 406-752-2843

McCone, Phillips, Richland,

Serving: Flathead, Lake, Lincoln,

Roosevelt, Sheridan, Valley, and

and Sanders Counties

Wibaux Counties

MONTANA DEPARTMENT OF NATURAL RESOURCES AND CONSERVATION

48 N. LAST CHANCE GULCH P.O. BOX 201601 HELENA, MT 59620-1601 444-6610

WEBSITE

Form 600 - Application For Beneficial Water Use Permit - 2001 Page 4

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