Form 651 C - Petition To Modify A Permit Or Change Authorization

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Form No. 651 C10/01/2013
PETITION TO MODIFY
A PERMIT OR
CHANGE AUTHORIZATION
FOR DEPARTMENT USE ONLY
Notice No. _________________ Basin _________________
Use this form to request modification or removal of a
Priority Date ________________ Time ___________AM - PM
condition or reduce the flow rate or volume of water
Rec'd By
_______________________________________
Fee Rec'd $ ____________
Check No. _____________
authorized on a permit or change authorization.
Deposit Receipt # __________________________________
§ 85-2-314, MCA
Payor (if different from name(s) listed in item 1 below)
__________________________________________________
Refund $
______________
Date __________________
Filing Fee $400.00
Deficiency Letter Sent ________________________________
*Important Note: It is strongly recommended that you contact the department to discuss the potential modification
prior to completing this form. Department personnel can assist you in determining what
information will be required for consideration of a Petition to Modify.
1.
WATER RIGHT OWNER INFORMATION:
NAME
____________________________________________________________________________________________________________
MAILING ADDRESS
____________________________________________________________________________________________________
CITY _________________________________
STATE
________________________
ZIP______________________________
WORK PHONE
_______________________
HOME PHONE____________________
CELL PHONE_____________________
2.
PERMIT OR CHANGE AUTHORIZATION NUMBER PROPOSED FOR MODIFICATION: _______________________________________________
3.
PROPOSED MODIFICATION: ______________________________________________________________________________________________
_______________________________________________________________________________________________________________________
4.
REASON FOR REQUEST- Describe in detail why you believe this modification is needed and warranted. If you are requesting removal or
modification of a condition attach any information you have that will assist DNRC in determining if the application criteria can be met
without the condition or with a modified condition. Please note that the criteria set out in § 85-2-311 for permit applications or § 85-2-402
for change applications must be met. The proposed modification may nullify, in full or in part, the evidence showing that one or more
criteria was met in the original application. New information must be provided to show that all applicable criteria will be met if the proposed
modification is granted. Attach additional sheets if necessary.
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
5.
AFFIDAVIT
I declare under penalty of perjury and under the laws of the state of Montana that the foregoing is true and correct.
Water Right Owner Signature
________________________________________________________
Date: ___________________
Water Right Owner Signature
________________________________________________________
Date: ___________________
Water Right Owner Signature
________________________________________________________
Date: ___________________
Go to web site
to learn additional information about the use of this form.

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