Form 647 - Notice Of Completion Of Emergency Fire Protection Development
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1Form No. 647 New 10/1/2011
NOTICE OF COMPLETION OF
EMERGENCY FIRE PROTECTION
DEVELOPMENT
Use this form for completed groundwater
FOR DEPARTMENT USE ONLY
developments where the appropriation was made
by a local governmental fire agency organized
Notice No. _________________ Basin _________________
under Title 7, chapter 33, and the appropriation is
Priority Date ________________ Time ___________AM - PM
Rec'd By
_______________________________________
used only for emergency fire protection, which
Fee Rec'd $ ____________
Check No. _____________
may include enclosed storage.
Deposit Receipt # __________________________________
Payor (if different from name(s) listed in item 1 below)
Incomplete forms will be returned.
__________________________________________________
Refund $
______________
Date __________________
Deficiency Letter Sent ________________________________
Filing Fee $125.00
Your priority is determined by the date of filing. If it is determined this form was improperly filed, your priority date may be changed.
If your development is within a Controlled Ground Water Area, the regional office will contact you to explain the correct filing requirements.
1.
NAME OF FIRE AGENCY (MUST HAVE BEEN ORGANIZED UNDER TITLE 7, CHAPTER 33)
____________________________________________________________________________________________________________
NAME OF CONTACT PERSON WITHIN THE FIRE AGENCY
____________________________________________________________________________________________________________
MAILING ADDRESS
________________________________________________________________________________________
CITY
_________________________________
STATE
________________________
ZIP
_________________________
WORK PHONE
_______________________
CELL PHONE
____________________
2.
DIVERSION USED TO OBTAIN GROUNDWATER FOR THE PURPOSE OF EMERGENCY FIRE PROTECTION
Well -
Attach well log, if available
Water Well Contractor Name: _________________________________________________________
Developed spring (Excavation performed at the spring location.)
3.
ENCLOSED STORAGE
Check if you utilize enclosed storage for the water -
Storage Capacity __________________________Gallons
Check if you do not utilize enclosed storage for the water.
4.
FLOW RATE USED ____________GPM
5.
COMBINATION OR SHARED DEVELOPMENT
a. Will this development be used in combination with another well or spring?
Yes
No
b. Will this development be shared by other users?
Yes
No
If yes for either question, list the water right numbers and explain how the development is used. ____________________________________
____________________________________________________________________________________________________________________
6.
PURPOSE AND PERIOD OF USE
Describe with as much detail as possible how and when the water will be put to use:
______________________________________________________________________________________________________
EMERGENCY
______________________________________________________________________________________________________
FIRE
______________________________________________________________________________________________________
PROTECTION
Year round use?
Yes
No
If no, from ____________ to _____________, inclusive of each year.
7.
POINT OF DIVERSION – Location of Ground water Development.
(
PLACE OF USE - For the purpose of Emergency Fire Protection the Place of use is the same as the Point of Diversion)
_____1/4 _____1/4 _____1/4 Section _____ Twp _____N / S Rge _____E /W County __________________________________________________
Lot _______ Block _______Tract No. _______
Subdivision Name ____________________________________________________________
Government Lot No. _____________________________
COS No.
__________________________________________________
Street or Road Address, including City, State & Zip Code of the Development __________________________________________________________
8.
AFFIDAVIT OF OWNERSHIP OR WRITTEN CONSENT
I have possessory interest in the property where the water has been put to beneficial use and I have the exclusive property rights
in the ground water development works OR I have attached written consent of the person owning the ground water development
works and/or written notification to the land owner pursuant to MCA 85-2-306(1).
The statements appearing here are to the best of my knowledge true and correct.
Appropriator's Signature
________________________________________________________
Date: ___________________
________________________________________________________
Date: ___________________
Go to web site
to learn additional information about the use of this form.
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