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~ <br />Oregon Water Resources Department <br />Land Use Information Form <br />THIS FORMIS NOTREQUIRED IF.• I) waeer is to be diverted, conveyed and/or used only on federal lands; or 2) the application is for a <br />water-right transfer, a/location of conserved water, exchnnge, permit amendment, or ground water regisMation madification, and al! of <br />the following apply: a) only the place ofuse fs proposed jor change, b) there are no stnrctura! changes, c) the use ofwater is for <br />irrigation, and d) the use is located in an irrigation district or exclusive farm-use zon~ <br />~~'~''' C/ , <br />ApplicantName:_4..~~1~-c d~ ~C9~°!ne (O ~et`Ctio ~,U ~t'~ <br />Mailing Address: 2~f~ £. ~ro 4. d+~ ~-~-1 <br />City: ~~aev~e State: C.~~2. Zip: ~~ O DayPhone: 541-682-5398 <br />This application is related to a Measure 37 claim. ^ Yes F~ No ~ <br />A. Land and Location <br />Please include the following information for ail tax lots where water will be diverted (taken from its source), conveyed <br />(transpoded), or used. Applicants for municipal use, or irrigation uses within irrigarion districts may subsritute exisring and <br />proposed service-area boundaries for the tax-lot informarion requested betow. <br />Township Range Secflon ~/. ~/. Tax Lot # Plan Designa6on (e.g. <br />Rural ResidendaVRR-5 Water to bei Proposed <br />Land Use: <br />17 04 16 200 E-40 0 Diverted 0 Conveyed 6 Used enhancement <br /> ^ Diverted ^ Conveyed ^ Used <br /> 0 Diverted ~ Conveyed ^ Used <br /> ^ Diverted 0 Conveyed ^ Used <br />List all counries and cities where water is proposed to be diverted, conveyed, or used. LANE COiJNTY <br />B. Descrintion of Proposed Use <br />Type of application w be filed with the Water Resources Deparhnent: <br />0 Pernut to Use or Store Water 0 Water-Right Traasfer ~ Exchange of Water <br />^ Allocation of Conserved Water ~ Limited Water Use License <br />^ Pemrit Amendment ar Ground Water Registration Modificadon <br />Source of water: 0 Reservoir/Pond ~ Ground Water 0 Surface Water (name) Cnlden (;ardens Ponds <br />Estimated quantity of water needed: I00 ^ cubic feet per second 0 galions per minute 0 acre-feet <br />Tntended use of water: 0 Trrigation 0 Commercial ^ Indnstrial ~ Domestic for <br />^ Municipal ^ Quasi-municipal O Instream ^ Other <br />Briefly deSCribO: Tem= nrar~ T~jgatinn fnr estahlishment of Native. Treec and Shn~hs ac nart nf~ and nafi~ral <br />re~onrce enhancement Water diversion will he from nond surface and irrigate nond shores_ irrigafion will he by <br />Portable ~u~»s tmder enntract with the City of F.ugene. <br />Note to appticant: If the Land Use Information Form cannoc be completed while you wart, please have a locat government <br />representative sign the receipt below and include it with the application ftled with the Water Resources DepaMment. <br />Receipt for Reauest for Land Use Information <br />State of Oregon <br />Water Resources Deparnnent <br />725 Summer Street NE, Suite A <br />Salem, OR 97301-1266 <br />household(s) <br />