Addition To Exemption Application Watershed Dam Or Reservoir


Addition to Exemption
KSA 79-201g
Page 1 of 1
Applicant Name: ________________________
Docket No. _____________________________
Addition to Exemption Application
Watershed Dam or Reservoir
K.S.A. 79-201g
Provide a complete copy of the Certificate of Completion of Dam and all attachments from the
Division of Water Resources.
Provide the legal description(s) of the real property owned by you which is contiguous to and a
part of the same tract of land upon which the dam or reservoir has been constructed.
I, ________________________________, do solemnly swear or affirm that the information set forth
herein is true and correct, to the best of my knowledge and belief. So help me God.
Signature of Applicant
Printed Name and Title
State of ____________________
County of __________________
This instrument was acknowledged before me on __________ by ______________________________.
Signature of Notary Public
My appointment expires: ________________
Revised 7/14


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