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P~ g 1)e <br />Point of Taking: <br />County: <br />City: <br />1/4 1/4 1/4, Section ,Township .Range <br />PID# (If <br />Estimated Pumping Rate: gallons per minute <br />Estimated Volume of Mater to be Appropriated: <br />Start of Pumping (date): <br />Point of discharge: <br />gallons <br />End of Pumping (date): <br />1/4 1/4 1/4, Section ,Township ,Range <br />PID# (If <br />Receiving Water (name and DNR ID # if applicable, <br />[ ] Stormsewer [ ]Basin [ ]Other (describe) <br />Approval (if required) has been received from the appropriate authorities for the proposed temporary <br />appropriation: [ ] Wate~h~l Nian~geinent ®rg lion [ ] Coa~nty <br />[ l unicip 'ty [ l T® hip [ l WCA Ruth®~ity <br />Applicant Signature <br />Date: <br />Area Hydrologist Authorization <br />[ ]See Attached Additional Conditions <br />Date: <br />FAX or mail this form and a map indicating the pump site and discharge location to the Area Hydrologist at <br />least five working days before the start of pumping. Provided that the Area Hydrologist did receive this <br />notification at least five working days in advance, pumping may commence as planned unless the applicant is <br />notified by the DNR to await further review. <br />c: Watershed 1Vlanagement Organization <br />County Soil and Water Conservation District <br />City <br />Area Conservation Officer <br />Central Waters Data Systems <br />Central Waters Appropriation Unit <br />