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, <br />OWNER IlVFORMATION: USER INFORMATION: If other than owner. <br />�e• Name: <br />Company (if applicable) Company (if applicable) <br />� dress: Address: <br />, State, Zip City, State, Zip <br />Daytime Phone Daytune Phone <br />� Number, email etc. Faac Number, email etc. <br />For Meter readers, whom shall we send the meter readings to? <br />�culation of Dues (due in my office by January 10`�, 2003) <br />Instructions for the items below are on page 1 and 2 of the AGUA application. Faxes of completed applications <br />�eived up to January 10th , will be accepted as long as the original is sent immediately after. <br />1. AGUA & Booth Administration (Non SWSP Wells Only) <br />� No. of wells $290.Q0 each <br />SWSP Wells (Gravel Pits) $200.00 (Plus Engineering Fees <br />Billed by the Engineer directly to the Well Owner) <br />� New Member No. of wells $25.00 each <br />Well Testing for wells that must be tested within the next year. <br />No. of wells $ each <br />� Please call the office for well test credit amount of payments already made. <br />Supplemental Plan #1 (for wells applying AFTER January 10"') <br />No. of wells $100.00 each (including excess engineering fees) <br />� Supplemental Plan #2 (for wells applying AFTER February 15th) <br />No. of wells $300.00 each (including excess engineering fees) <br />8. Inactive Wells No. of wells $76.00 each <br />t Total Dues <br />Tota.l: <br />Total: <br />Total: <br />Total: <br />Total: <br />Total: <br />Total: <br />Grand Total *: <br />* Make checks payable to AGUA <br />�Acre-feet of Water Needed to be augmented (total pumping, not depletions) for the Plan Year Pumping Season (April 1$` to <br />March 31 We cannot process your applicarion without this information! Any AGUA well that has been used for irrigation in <br />� vious years can submit a request for the amount of water they would like to have for the 2003 plan year in the event that <br />UA obtains enough replacement water. The domestic & Municipal users are asked to make sure they don't over estimate their <br />need for water, as they have had a tendency to do that in the past. Water requested for those wells must Ue for just enough water <br />� et them by and no more or we will base it on previous use. <br /># Of wells / Farm Unit # Acres Cro U ( A F t T' f th d d� <br />' <br />p or se use a cre ee ime o e year nee e. <br />and or ID # Irrigated separate line for in- needed from the <br />(if applicable) house use or stock) wells <br />� <br />For multiple or multiple use wells use a separate line for ordering water. If one well has two or more pumps with different uses, <br />�u must put down how many acre feet each pump will need for the year. OR, if the State has given your wells a different <br />'�a.rm Unit" number, you must allocate each Farm Unit a certain a.mount of water. If needed, please call the ofFce for more <br />information. <br />�ave read and understand the application and believe that the information given is conect to the best of my ability. <br />Signature of Owner Date <br />' <br />application 2003 VER 12-20-02 <br />