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2. FORM 200

   Operating and Transfer Permit Application

4. First Name*
5. Last Name*
7. Organization*

   Please type the name of your organization/company.

9. Phone Number*
10. Email Address*
14. SECTION I – PURPOSE FOR WATER USE: NON-EXEMPT ONLY
16. Type of Well:*
18. List Proposed Usage of Water Produced from Well and the Amount of Usage.
20. Proposed Usage of Water Produced from Well*
21. Proposed Amount of Water Used from Well (af/yr)*
23. Will this well be used to export water outside the boundaries of LPGCD?*
    -- Select One --YesNo
25. If yes to the question above what is the maximum annual withdrawal (af/yr)?
27. Proposed rate at which water will be withdrawn (gallons/min):*
29. List CCN# of entity to benefit from water:*
31. Number of L.U.E. to be utilized by water usage:*
35. SECTION II – BENEFICIAL USE: NON-EXEMPT ONLY
37. Please state beneficial use of well:*
39. Upload a letter here if more space is necessary to state the beneficial use of the well.
43. SECTION III – PLANS: NON-EXEMPT ONLY

    Please upload copies of the following Schedules or Logs, if applicable.

45. Well Closure Plan or Declaration
46. Alternative Supply Plan
47. Conservation Plan
48. Aquifer Impact
52. SECTION IV – AFFIRMATION AND EXECUTION
54. in signing this I certify that all statements and information in this application are true and correct.*

    Please type your first and last name as a digital signature.

55. Date*
    Date

    Please enter today's date.

57. Please upload Notary statement here.*
Leave This Blank:


59. 1. Receive an email copy of this form.
60. Email address

    This field is not part of the form submission.

61. Submit

* indicates a required field