DO YOU NEED A CONSUMPTIVE USE PERMIT?


YES NO

1. Do your withdrawal facilities (include ganged wells) have the capacity

of withdrawing one million (1,000,000) or more gallons per day? *


2. Is the proposed withdrawal greater than .one million (1,000,000)

gallons per day, or is the average withdrawal greater than one hundred

thousand (100,00) gallons per day?


3. Is the proposed withdrawal to be from a well with an inside diameter

of six (6) inches or more? .......






If any answer is yes you do need to complete the application enclosed as explained

in the Information/Instruction Booklet. If all of the answers are "no", you do not need a consumptive use

permit. Mark an "X" in the block provided on the enclosed envelope and return the unused packet.




Name Signature


Address Date


City, State, Zip Code