EXH0578023786

PCHBPollution Control Hearings Board of the State of Washington

For filing with Ecology' or with County Conservancy Boards A MINIMUM FEE OF $10.00 PAYABLE TO ECOLOGY MUST ACCOMPANY THIS APPLICA T/ON J.i • ii. i (Check Blithe/ a_l_ly.) FOR OFFICE USE ONLY _ Ctlange purpose(s) of use AOCl purpose(s) of use CHANGE No. _,_'_-,,_ WRIA Change point(s) Of clJversioniwithclrawal [] ACI¢ point(s) of diversion/withorawal DATE ACCEPTED _ /. _ _ BY_j_ Change/transfer place of use FEE $ /_ - _-_ REC*D _ / {--70tl_er (i.e. consoliclation, Intertie, trust water) .... Explain: CHECK No. / ==El=A: ,_Exempt r'l Not exempt "'IF MORE SPACE IS NEEDED, A T'I'ACH _DDITIONAL SHEETS (PLEASE PRINT OR TYPE CLEARL _'* 1. Applicant Information: l- APPUCANTIB._ INESS NAIVJE I PHONE NO. t FAX NO. ] L--. /_rz-__---,/.;_, 2. Water ,Right Information: DO YOU OWN THE RIGHT TO BE CHANGED? (!_ YES I_ NO V ". IF NO. PROVIDE OWNER(S) NAME: HAS THE WATER BEEN I_UT TO BENEFICIAL USE IN THE LAST FIVE (5) YEARS? _ YES 1"3 NO Please attach copies of any docMmentation th=_t demonstrates consistent, historical use of wolff a/nee the right was esrabltshecl. Also, if you have a water sy_'ctem plan or conservation plan, please inclucle a c_py with your a_plica tion. i,, , i j i ii i ! FOR OFFICE uSE ONL Y _p__._! APP.…
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