Easement Application Form Date Received: Across State Land or Waterbody /dsl (West of the Cascade Crest) (East of the Cascade Crest) Mail completed application with the non-refundable WESTERN REGION EASTERN REGION application fee, made payable to Department of State Lands Department of Lands Oregon Department of State Lands. 775 Summer Street NE, Suite 100 1645 NE Forbes Rd, Suite 112 Salem, OR 97301-1279 Bend, OR 97701 503-986-5200 541-388-6112 We accept Visa & Master Card; please call (503) 986-5200 FAX: 503-378-4844 FAX: 541-388-6480 Please indicate Existing: For Office Use Only: Oregon Department of State Lands Application No._______ AGENCY WILL ASSIGN NUMBER Oregon Department of State Lands Application No.________ - APPLICANT INFORMATION Applicant Private Facility Government Entity PUC Regulated Utility Person is: Applicant’s Name and Address: Home Business Fax: Co-Applicant’s Name and Address: Home Phone: Business Fax: Email: Authorized Agent’s Name and Address: Home Phone: Business Phone: Fax: Riparian Property Owner Name and Address: Home Phone: (vested); if different than applicant Business Phone: Fax: Email: - PROJECT LOCATION Street, Road or other descriptive location Legal Description Township Section Quarter In or Near (City or Town) County Tax Map # Tax Lot # Waterway River Mile County Property Tax Account Number
Easement Application Form Across State Land or Waterbody /dsl Date Received: (West of the Cascade Crest) WESTERN REGION Department of State Lands 775 Summer Street NE, Suite 100 Salem, OR 97301-1279 503-986-5200 FAX: 503-378-4844 Mail completed application with the non-refundable application fee, made payable to Oregon Department of State Lands. We accept Visa & Master Card; please call (503) 986-5200 (East of the Cascade Crest) EASTERN REGION Department of Lands 1645 NE Forbes Rd, Suite 112 Bend, OR 97701 541-388-6112 FAX: 541-388-6480 For Office Use Only: AGENCY WILL ASSIGN NUMBER Oregon Department of State Lands Application No.________ Please indicate Existing: Oregon Department of State Lands Application No._______ - APPLICANT INFORMATION Applicant is: Private Facility Government Entity PUC Regulated Utility Person Applicant’s Name and Address: Home Business Fax: Co-Applicant’s Name and Address: Home Phone: Business Fax: Email: Authorized Agent’s Name and Address: Home Phone: Business Phone: Fax: Riparian Property Owner Name and Address: (vested); if different than applicant Home Phone: Business Phone: Fax: Email: - PROJECT LOCATION Street, Road or other descriptive location Legal Description Township Section Quarter In or Near (City or Town) County Tax Map # Tax Lot # Waterway River Mile County Property Tax Account Number
app_easment.docx