A street or highway location map with road directions to the site from the nearest main highway or road. Assessor map that contains the riparian uplands. Do not mark on this map. A copy of the current year’s property tax statement which identifies the present owner’s name(s), land values, land size and tax account numbers of the riparian uplands. A legal description of the requested easement area with an accurate delineation of the area relative to the tax lot boundaries of the upland parcel. (The department may require a survey for this purpose). A separate drawing to scale of all existing and proposed structures for the easement area. Label each separate activity type stated in Section 3 and show the dimensions of each area by length and width, as stated in Section 3. Non-refundable application fee of $125.00 for water pipeline and associated fixtures or $750.00 for all other easement requests. - APPLICANT SIGNATURE I hereby request a state authorization for (number) years. (The maximum easement term is 30 years. The Department may issue permanent easements for qualifying uses. Application is hereby made for the activities described herein. I certify that I am familiar with the information contained in the application, and, to the best of my knowledge and belief, this information is true, complete, and accurate. I further certify that I possess the authority to undertake the proposed activities. I understand that the granting of other permits by local, county, state or federal agencies does not release me from the requirement of obtaining the authorization requested before commencing the project. I understand that payment of the required state application fee does not guarantee authorization. Print /Type Name Title ____________ Applicant Signature Date I appoint the person named below to act as my duly authorized agent. Print /Type Name Title ____________ Authorized Agent Signature Date
A street or highway location map with road directions to the site from the nearest main highway or road. Assessor map that contains the riparian uplands. Do not mark on this map. A copy of the current year’s property tax statement which identifies the present owner’s name(s), land values, land size and tax account numbers of the riparian uplands. A legal description of the requested easement area with an accurate delineation of the area relative to the tax lot boundaries of the upland parcel. (The department may require a survey for this purpose). A separate drawing to scale of all existing and proposed structures for the easement area. Label each separate activity type stated in Section 3 and show the dimensions of each area by length and width, as stated in Section 3. Non-refundable application fee of $125.00 for water pipeline and associated fixtures or $750.00 for all other easement requests. - APPLICANT SIGNATURE I hereby request a state authorization for (number) years. (The maximum easement term is 30 years. The Department may issue permanent easements for qualifying uses. Application is hereby made for the activities described herein. I certify that I am familiar with the information contained in the application, and, to the best of my knowledge and belief, this information is true, complete, and accurate. I further certify that I possess the authority to undertake the proposed activities. I understand that the granting of other permits by local, county, state or federal agencies does not release me from the requirement of obtaining the authorization requested before commencing the project. I understand that payment of the required state application fee does not guarantee authorization. Print /Type Name Title ____________ Applicant Signature Date I appoint the person named below to act as my duly authorized agent. Print /Type Name Title ____________ Authorized Agent Signature Date
app_easment.docx