File Number: _______________
(For OSE Use Only)
NEW MEXICO OFFICE OF THE STATE ENGINEER
NOTICE OF INTENTION TO MAKE FORMAL
APPLICATION FOR PERMIT TO APPROPRIATE SURFACE WATER
1. APPLICANT
Name: _________________________________________
Work Phone: ____________
Contact: _________________________________________
Home Phone: ____________
Address: _________________________________________
_________________________________________
City: _________________________________________ State: __ Zip: __________
2. POINT OF DIVERSION (A, B, C, or D required, E or F if known)
A. ____1/4
____1/4
____1/4 Section:____ Township:____
Range:____ N.M.P.M.
in ______________________________________________________________ County.
B. X =_____________ feet, Y = _________________ feet, N.M. Coordinate System
__________ Zone in the ___________________________________________ Grant.
U.S.G.S. Quad Map _____________
C. Latitude: ______d _____m _________s
Longitude: ______d _____m _________s
D. East __________ (m), North __________ (m), UTM Zone 13, NAD __ (27 or 83)
E. Tract No. _____, Map No. _____ of the _______________ Hydrographic Survey
F. Lot No. _____, Block No. _____ of Unit/Tract _____________________ of the
____________________ Subdivision recorded in ____________________ County.
G. Other: __________________________________________________________________
H. Give State Engineer File Number if existing diversion: __________________
I. On land owned by (required): ____________________________________________
J. Source of surface water supply:
a. Name of ditch, acequia, or spring: ___________________________________
b. Stream or water course: ______________________________________________
c. Tributary of: ________________________________________________________
3. QUANTITY
Diversion Amount: __________ acre-feet per annum
Consumptive Use:
__________ acre-feet per annum
4. PURPOSE OF USE
Domestic: ___ Livestock: ___ Irrigation: ___ Municipal: ___ Industrial: ____
Commercial: ___ Other (specify): ___________________________________________
Specific use: ______________________________________________________________
__________________________Do Not Write Below This Line________________________
File Number: _______________
Trn Number: _______________
Form: wr-15
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