DIVISION OF WATER RIGHTS

State of California

State Water Resources Control Board

DIVISION OF WATER RIGHTS

1001 I Street, 14th Floor, Sacramento, CA 95814

P.O. Box 2000, Sacramento, CA 95812-2000

Info: (916) 34 1-5300, Fax: (916) 341-5431, waterboards.waterrig_hts'

INITIAL STATEMENT OF WATER DIVERSION AND USE

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NOTE: A Statement is not a Water Right

This Statement should be typewritten or legibly written in ink and submitted to the address above. A separate statement must be filed for each point of diversion.

WR-61

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An (*) indicates a required section. Required sections must be completed for the Statement to be accepted.

*A. ClaimanUAgent Information

Claimant:

Agent:

Mailing Address

Phone No.

Fax No.

E-mail Address:

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X...,.. *B. Water is diverted and used under the ciaim of: Riparian claim __ Pre 1914 claim

Other (explain):

Court Decree No _ _ __

?c. Name of the body of water at the point of diversion

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Tributary to \;::-\ # \Jl.o'.-t:h,

':21 $\:;.; *D. Point of diversion is located within

30":i

SW_ 3,~ being within the

1/4 of ~

1/4 of Section

County on Assessor's Parcel No ._ _ __ _ _ _ _ _ _ __

\3 r\J . of Township

? Range (Q_ {2. , _ti_ B&M.

Provide the location of the point of diversion using the California Coordinate System or Latitude/ Longitude measurements.

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Identify the point of diversion and outline the pla e of use on a United States Geologica l Survey {USGS) topographic map and

s ubmit the map with the Statement.

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~""'!.~~ Name of lhe diversion works ,s

~V\e-M.~..n2l u:w..~

- Related Waler Right(s)

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E. Do you own the land at the poin t of diversion? Yes_ No ~ If No, please provide the name and address of the land owner at the point

of diversion:? - -- - -- -- - - - -- - - - - - - - - - - - - - - - - - - - -- - - - - - - -

NOTE: Item "F" is optional until January 1, 2012, at which time the information becomes mandatory.

3C-+$ *F. Capacity of diversion works

(cfs. gpm. or gpd) Capacity of storage tanks or reservoir - - - - (gallons or acre-feet)

_x__ Type of diversion facility: Gravity

Creek Pump _ _ _ Well Pump _ __

-2(_ _X_. _ Method of measurement: Weir _ _ Flume

In line How meter _ _ Electric Meter _ _ _ Estima te

Provide the average rate of diversion each month in the table below as measured in: cfs ~ . gpm _ . or gpd _

Year Jan

Feb

Mar

Apr

May

June July

Aug

Sept Oct

Nov

Dec

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Additional copies of this form and water right information can be obtained al www waterboards.ca gov/waterrightslpublicalions forms/

S01 6375

002024

' G. Provide the quantity of water used each month in the table below as measured in: Gallons

Million gallons ~ Acre-feet

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Total

Year Jan

Feb

Mar

Apr

May

June July

Aug

Sept

Oct

Nov

Dec

Annual

.s ti?\ o/t:l.- ?f.?, t;~:z~ ~~;1... ?1-'\/ ~-7 +?.l?2 a;f>~ 1$ c;i.'L 5-r.i., )?."L ~?fi.,

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, California

:2. ~~ 'SIGNATURE:

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*PRINTED NAME:

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