Form No. 600 R8/2010
APPLICATION FOR
BENEFICIAL WATER USE PERMIT
Use for ground water in excess of 35 gpm or 10 acre-feet per year
and for all surface water.
Use one application for each source of supply or each development. Check all appropriate boxes
FOR DEPARTMENT USE ONLY
and fill in each blank. If more space is needed, attach properly labeled additional information. To
avoid processing delays, submit all required information.
Application #
Basin
FILING FEE
Priority Date
$800.00
Inside a Basin Closure Area, Controlled Ground Water Area, or Compact Area
Time
AM / PM
all ground water in excess of 35 gpm or 10 acre-feet per year and for all surface
water.
Rec'd By
$600.00
Outside of a Basin Closure Area, Controlled Ground Water Area, or Compact
Fee Rec'd $
Check #
all ground water in excess of 35 gpm or 10 acre-feet per year and for all surface
water.
Refund
Date
$200.00
In a Controlled Ground Water Area - ground water appropriation less than 35 gpm
and 10 acre-feet per year.
1. NAME OF APPLICANT
Mailing address
City or Town
State
Zip
Phone
Email Address
2. SOURCE OF WATER SUPPLY
Well Estimated Depth in Feet
Developed Spring Name
Lake Name
Tributary to
Stream Name
Unnamed Source - Tributary to
Closed Basin (A closed basin results when water drains into a depression, lake, etc. from which water escapes only by
evaporation.)
Other
3. POINT OF DIVERSION Describe the location to the nearest 10 acres.
1/4
1/4
1/4 Sec
Twp
N/S Rge
E/W County
(a)
Lot
Block
Tract No.
Subdivision Name
Government Lot
Latitude
Longitude
1/4
1/4
1/4 Sec
Twp
N/S Rge
E/W County
(b)
Lot
Block
Tract No.
Subdivision Name
Government Lot
Latitude
Longitude
4. MEANS OF DIVERSION
Pump
Headgate
Rated Capacity (GPM or CFS)
Pipeline (description)
Horsepower
Dam (Complete item 5)
Lift in Feet
Pit (Complete item 5)
Other
Describe your plans for measuring your water use:
Application For Beneficial Use Permit, Form 600 ~ R8/2010
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