Water Permit Application Form

WATER PERMIT APPLICATION FORM

This Water Permit Application (the Agreement) is submitted by Applicant Name: , whose mailing address is Address: , and contact information is Phone: Email: , to Issuing Authority: on Application Date: .

RECITALS

WHEREAS, the Applicant seeks authorization to withdraw, divert, or use surface water or groundwater for the purposes described herein; and

WHEREAS, the Issuing Authority is charged with the administration and enforcement of applicable statutes, regulations and local ordinances governing water use and has authority to grant permits subject to conditions necessary to protect public resources; and

WHEREAS, the Applicant has provided the factual and technical information required by the Issuing Authority for review of the requested permit.

NOW THEREFORE, in consideration of the mutual covenants and representations set forth below, the Applicant submits this application and agrees to comply with all terms and conditions this Permit may impose.

1. PERMIT REQUEST

1.1 Permit Type (check all that apply): Surface Water Groundwater Storage/Reservoir

1.2 Purpose of Use (select primary): Irrigation Public Supply Industrial Other

2. PROJECT DESCRIPTION

3. LOCATION AND PROPERTY

3.1 Physical Location of Withdrawal or Diversion: Coordinates (Lat/Long) Parcel ID/Lot Number:

4. WATER SOURCE AND QUANTITIES

4.1 Source Name: Type:

4.2 Requested Maximum Withdrawal Rate (per day): Volume per Year:

4.3 Proposed Start Date: Anticipated End Date (if applicable):

5. MONITORING, REPORTING AND METERING

5.1 The Applicant shall install and maintain metering and monitoring equipment acceptable to the Issuing Authority. The Applicant's monitoring plan is summarized as:

5.2 Reporting Frequency: Reports shall include measured withdrawal volumes, calibration records, and any incidents of exceedance or malfunction.

6. TERM, RENEWAL AND TRANSFER

6.1 Term: The permit term sought is Term Length (years): commencing on the effective date of authorization.

6.2 Renewal: Renewal of any permit will require submittal of a renewal application and demonstration of compliance with all permit conditions and applicable law. Renewal is subject to review and may include additional conditions.

6.3 Transfer: The permit shall not be transferred without prior written approval of the Issuing Authority and may require submission of a transfer application and fees.

7. FEES, SECURITY, AND FINANCIAL ASSURANCES

7.1 The Applicant shall pay all required application, processing and permit fees in accordance with Issuing Authority fee schedules. Fee Amount Submitted: .

7.2 The Issuing Authority may require a security, bond or other financial assurance to ensure compliance with permit conditions; such security shall be in a form acceptable to the Issuing Authority.

8. COMPLIANCE, INSPECTION AND ENFORCEMENT

8.1 The Applicant shall comply with all applicable federal, state and local laws, regulations and permit conditions. Noncompliance shall be grounds for enforcement action, modification, suspension or revocation of any permit issued.

8.2 The Issuing Authority or its authorized representatives shall have the right to enter the property at reasonable times for inspection, monitoring, or enforcement. The Applicant shall provide reasonable access and shall not interfere with inspections.

9. REPRESENTATIONS, WARRANTIES AND CERTIFICATION

9.1 The Applicant represents and warrants that all information provided in this application, and in any accompanying documents, is true, complete and accurate to the best of Applicant's knowledge. The Applicant recognizes that intentional misrepresentation or omission of material facts may result in denial, rescission or revocation of any permit and civil or criminal penalties.

9.2 Certification: By signing below, the Applicant certifies under penalty of law that they are authorized to make this application and that the foregoing statements and attachments are true and complete.

10. INDEMNIFICATION

The Applicant shall indemnify, defend and hold harmless the Issuing Authority, its officers, agents and employees from and against any and all claims, liabilities, damages, losses and expenses, including reasonable attorney fees, arising out of or in connection with the Applicant’s activities authorized by the permit, except to the extent caused by the Issuing Authority’s gross negligence or willful misconduct.

11. NOTICES

11.1 All notices required or permitted under this application shall be in writing and delivered to the contact information provided above for the Applicant and to the Issuing Authority contact designated upon permit issuance. Notice by mail is effective upon deposit with the postal service; notice by personal delivery is effective upon receipt.

12. AMENDMENTS, WAIVER AND SEVERABILITY

12.1 Amendments to any permit or to this application must be made in writing and signed by both the Applicant and the Issuing Authority, except where the Issuing Authority is expressly authorized by statute or regulation to make administrative modifications.

12.2 No waiver by either party of any breach or default shall be deemed a waiver of any subsequent breach or default. Failure to exercise any right shall not operate as a waiver of that right.

12.3 If any provision of this application or any permit issued pursuant hereto is held to be invalid or unenforceable by a court of competent jurisdiction, the remaining provisions shall remain in full force and effect.

13. GOVERNING LAW

This application and any permit issued in connection with it shall be governed by and construed in accordance with the laws and regulations of the jurisdiction where the withdrawal occurs, without regard to conflict of law principles.

14. ENTIRE AGREEMENT

This application, together with any exhibits, attachments and conditions included in any permit issued hereunder, constitutes the entire understanding between the Applicant and the Issuing Authority regarding the subject matter and supersedes all prior and contemporaneous agreements and representations.

15. COUNTERPARTS AND ELECTRONIC SUBMISSION

This application may be executed in counterparts, each of which shall be deemed an original, and all of which together shall constitute one and the same instrument. Electronic copies and signatures shall be effective to bind the parties to the same extent as original signatures.

ADDITIONAL ATTACHMENTS

SIGNATURES

The Applicant certifies that the information contained in this application and accompanying documents is true and complete and that the Applicant will comply with all applicable laws and permit conditions if a permit is granted. The Issuing Authority acknowledges receipt of this application for review and retains discretion to approve, deny, condition or modify any permit authorization in accordance with applicable law.

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