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DEPARTMENT OF Y~TLR~L RESOURCES Water Appropriation General Permit Notification Form General Permit 97-0005 requires that the Area Hydrologist be notified five days before the start of water appropriations. Please fill in the items listed below and fax or mail this form to the Area Hydrologist (see back of form) for the county in which the water appropriation is located. This notification form is only for temporary appropriations authorized by General Permit 97-0005. Applicant Name: Address: Telephone: - (Area Code) FAX: - (AreaCode) Purpose: [ ]Construction Dewatering [ ]Hydrostatic Testing of Pipelines or Tanks [ ]Landscaping or Dust Control [ ]Hydrostatic Testing of Wastewater Ponds Project Description (including depth of wells, dewatering depth, well size, etc...): Source of Water: [ ]Well(s), if so how many? _ [ ]Water Truck [ ]Pump(s) [ ] Land Access Authorization to Source: [ ]Construction Easement [ ]Landowner Permission (provide info below) Land Owner Name:_ Land Owner Address: Point of Taking: Contact Person: County 1/4 1/4 t/4, Section ,Township ,Range Estimated Pumping Rate: gallons per minute Estimated Total'Volume to be Appropriated: Start of Pumping (date): End of Pumping (date): Point of discharge for construction dewatering and hydrostatic testing water: gallons 1/4 1/4 1/4, Section ,Township ,Range Name of Receiving Water:. Land Access Authorization. to Discharge: [ ]Construction Easement [ ]Landowner Permission (provide info below) Land Owner Name:_ Land Owner Address: Phone #: Phone #: By signing below I certify the information submitted is true and correct to the best of my knowledge. pp tcant tgnature Date: / / Date: / / rea y ro ogtst ut ortzation FAX or mail this form, a map showing the pumping and discharge sites, and any other supporting information to the Area Hydrologist at Least five days before the start of pumping. Failure to provide information requested in this notification form can delay approval under the general permit.