assisted in preparing this above application, I understand that all responsibility for the accuracy of the information rests with me. Applicant Printed Name Title Applicant Signature (Date: MM/DD/YYYY) – Water Right Holder Printed Name Water Right Holder Signature (Date: MM/DD/YYYY) Land Owner of Existing Place of Use Printed Land Owner of Existing Place of Use Signature (Date: MM/DD/YYYY) Name Land Owner of Proposed Place of Use Printed Land Owner of Proposed Place of Use (Date: MM/DD/YYYY) Name Signature Central Regional Office Eastern Regional Office 1250 W. Alder Street 4601 N. Monroe Street *Submit your application to: Gap, WA 98903-0009 Spokane, WA 99205-1265 (509) 575-2490 (509) 329-3400 DEPARTMENT OF ECOLOGY CASHIERING SECTION PO BOX 47611 Northwest Regional Office Southwest Regional Office OLYMPIA, WA 98504-7611 3190 160th Avenue SE PO Box 47775 – Bellevue, WA 98008-5452 Olympia, WA 98504-7775 (425) 649-7000 (360) 407-6300 ATTACHMENT FOR Application for Change/Transfer of Water Right Point(s) of Diversion/Withdrawal - Existing Proposed: SOURCE NO. ¼ ¼ SEC. TWP. RGE. PARCEL # WELL TAG # DO YOU OWN THE ABOVE POINT(S) OF DIVERSION/WITHDRAWAL? YES NO IF NO, PROVIDE OWNER NAME(S): Purpose(s) of Use - Existing Proposed: PURPOSE OF USE GPM or CFS ACRE-FT/YR PERIOD OF USE
assisted in preparing this above application, I understand that all responsibility for the accuracy of the information rests with me. Applicant Printed Name – Title Applicant Signature (Date: MM/DD/YYYY) Water Right Holder Printed Name Water Right Holder Signature (Date: MM/DD/YYYY) Land Owner of Existing Place of Use Printed Name Land Owner of Existing Place of Use Signature (Date: MM/DD/YYYY) Land Owner of Proposed Place of Use Printed Name Land Owner of Proposed Place of Use Signature (Date: MM/DD/YYYY) *Submit your application to: DEPARTMENT OF ECOLOGY CASHIERING SECTION PO BOX 47611 OLYMPIA, WA 98504-7611 Central Regional Office 1250 W. Alder Street Gap, WA 98903-0009 (509) 575-2490 Eastern Regional Office 4601 N. Monroe Street Spokane, WA 99205-1265 (509) 329-3400 Northwest Regional Office 3190 – 160th Avenue SE Bellevue, WA 98008-5452 (425) 649-7000 Southwest Regional Office PO Box 47775 Olympia, WA 98504-7775 (360) 407-6300 ATTACHMENT FOR Application for Change/Transfer of Water Right Point(s) of Diversion/Withdrawal - Existing Proposed: SOURCE NO. ¼ ¼ SEC. TWP. RGE. PARCEL # WELL TAG # DO YOU OWN THE ABOVE POINT(S) OF DIVERSION/WITHDRAWAL? YES NO IF NO, PROVIDE OWNER NAME(S): Purpose(s) of Use - Existing Proposed: PURPOSE OF USE GPM or CFS ACRE-FT/YR PERIOD OF USE
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