Water Use Permit Application

APPLICATION FOR WATER USE PERMIT
Pawnee Nation of Oklahoma Division of Natural Resources and Safety

Phone: 918.762.3655 | Fax: 918.762.6461 | Email:dnrs@pawneenation.org 301 Agency Road, P.O. Box 470, Pawnee, OK 74058
Pawnee Nation Code of Laws Title XII, Chapter 15
PERMIT TYPE
If Other, State Purpose (Special Permit)
APPLICANT - PERSON, ORGANIZATION, OR WATER SYSTEM
Name
Email
example@example.com
Mailing Address
Work Tel
City
State
Zip
Fax
Are you a Pawnee tribal member?
Pawnee Enrollment No.
CONTACT - PERSON TO CALL ABOUT THE APPLICATION
Name
Email
example@example.com
Mailing Address
Work Tel
City
State
Zip
Fax
Relationship to Applicant
STATEMENT OF INTENT
ATTACH A "LEGAL" DESCRIPTION OF THE PLACE OF USE.
The applicant request a permit to use not more than:
Type either gallons per minute or cubic feet per second
Type of water source
Purpose for requesting a permit:
Attach a *LEGAL* description of the place of use.

Cancelof
Estimate a maximum annual quantity to be used in acre-feet per year
Check if the water use is proposed for a short-term project.
Start Date the water will be needed:

MonthDayYear
Start Date
End Date the water will be needed:

MonthDayYear
Start Date
WATER SOURCE
IF SURFACE WATER:

Name the water source and indicate if stream, spring, lake, etc. If unnamed, write "unnamed spring," "unnamed stream," etc.:
Number of diversions
Source flows into (name of body of water)
IF GROUND WATER:
A permit is desired for
Lummi Well Identification Nos
Size and depth of well(s)
LOCATION
Enter the north-south and east-west distances in feet from the point of diversion or withdrawal to the nearest section corner:
1/4 of
1/4 of
1/4 of
Township
Range (E/W)
Section
If location of source is platted, complete below:
Lot
Block
Subdivision
GENERAL WATER SYSTEM INFORMATION
A.Name of system, if named
B.Briefly describe your existing or proposed water system.
C.Do you already have any water rights or claims associated with this property or system?
Provide Documentation if YES

Cancelof
DOMESTIC / PUBLIC WATER SUPPLY SYSTEM INFORMATION
A. Number of Connections requested
Type of Connection (Home, PWS, etc.)
B. If PWS, Gallons per day Raw Water for distribution
Type of Treatment
C. If PWS, Treatment Type:
Certified Operator #
D. If PWS, are Water Conservation Plans in place
If not, target date of completion:

MonthDayYear
Date
(Complete for all irrigation and agriculture uses
A.Total number of acres to be irrigated
B. List total number of acres for other specified agricultural uses:
Use #1
Acres #1
Use #2
Acres #2
Use #3
Acres #3
C.Total number of acres to be covered by this application
D. Farm uses:
Stockwater – Total # of animals Dairy
Stockwater – Animal type
If dairy cattle, see below
Dairy – # of Milking
Dairy – # of Non-milking
Water Storage
Will you be using a dam, dike, or other structure to retain or store water? (If yes, please describe the storage facility (elevation, dimensions, capacity, material and provide a map showing location.)
REQUIRED MAP
A.Attach a map of the project.
File Upload

Cancelof
Property Ownership
A. Does the Applicant own the land on which the water will be used?
If no, explain the applicant’s interest in the place of use and provide the name(s) and address(es) of the owner(s)
B. Does the Applicant own the land on which the water source is located?
I certify that the information above is true and accurate to the best of my knowledge. I understand that in order to process my application, I grant staff from the Pawnee Nation Department of Environmental Conservation and Safety access to the site for inspection and monitoring purposes. Even though I may have been assisted in the preparation of the above application by the employees of the Pawnee Nation, all responsibility for the accuracy of the information rests with me.
Applicant (or Authorized Representative)
Date

MonthDayYear
Date
Should be Empty:

APPLICATION FOR WATER USE PERMIT

APPLICANT - PERSON, ORGANIZATION, OR WATER SYSTEM

STATEMENT OF INTENT

WATER SOURCE

LOCATION

GENERAL WATER SYSTEM INFORMATION

DOMESTIC / PUBLIC WATER SUPPLY SYSTEM INFORMATION

REQUIRED MAP

Property Ownership