______________________________
(School Name)
Department of Agriculture Division of Water Resources

*File Number _____________

STUDENT APPLICATION
FOR
PERMIT TO APPROPRIATE WATER FOR BENEFICIAL USE
-------------------------

1.
 

Name of applicants (Please Print):

________________________________________

________________________________________

________________________________________

________________________________________

School Address: Classroom:

________________________________________

Address:

________________________________________

City, State, Zip Code:

________________________________________

School Telephone Number:

(_____)__________________________________

2.

 Source of groundwater is in ______ surface water (stream) or ______ groundwater. (Check one)

3.

 The maximum quantity of water desired is __________ acre-feet per simulated year.
 

4.

The location of the proposed well(s), pump site(s), or other work(s) for diversion of water is: (Complete one section for each well desired)

(A)

 One in chamber______of section______ on the____________farm in___________
  ________________________________ classroom, in_____________Township, in
  ________________________________ County, Kansas.

(B)

 One in chamber______of section______ on the____________farm in___________
  ________________________________ classroom, in_____________Township, in
  ________________________________ County, Kansas.

(C)

 One in chamber______of section______ on the____________farm in___________
  ________________________________ classroom, in_____________Township, in
  ________________________________ County, Kansas.

 

5.

The water is intended to be appropriated for (Check the intended Use):

(a)___Artificial Recharge

(c)___Irrigation Use

(e)___Recreation Use

(g)___Water Power Use

(b)___Industrial Use

(d)___Municipal Use

(f)___Stockwatering Use

  

 

6.

 The works for diversion of water will consist of how many wells ____, pumps ____, or dams ____ and will be completed by (date, month, and year) __________________________.
 

7.

 The first actual application of water for the proposed beneficial use is estimated to be ____________ ____________________ (date, month, and year).
 

8.

 Will pesticide, fertilizer, or foreign substance be injected into the water pumped from the diversion works? Yes____ No____
 

9.

 The application must be supplemented by a map showing the proposed points of diversion (wells, stream-bank installations, dams, or other diversion works) and the areas to be supplied by such diversions (See attachment).
 

10.

 Once this application is filed at the headquarters office of the Division of Water Resources assigned a priority number, the maximum requested quantity of water can not be increased. Please be certain that your requested amount is appropriate and reasonable for your proposed project and is in reason with the Division of Water Resources policy.

11.

The undersigned states that the above information is true to the best of his/her knowledge and that this application is submitted in good faith.

Dated at__________________________ , Kansas, this_____day of__________, 19____ .
  . . . . . . . . . . (date). . . . . . .(month).. . . . .(Yr.)
_________________________________ , _____________________________________ ,
_________________________________ , _____________________________________ ,

(Applicant's

 Signatures)
   
_________________________________ , _____________________________________ ,
_________________________________ , _____________________________________ ,

 (Agent's

 Signatures)



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irc staff 11/28/97 (updated kn 06/17/99)
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