STATE OF WYOMING

Form S.W. 4 _____________ Rev. 6.2.2006

NOTE: Do not fold this form. Use typewriter or print neatly with black ink.

STATE OF WYOMING

OFFICE OF THE STATE ENGINEER

APPLICATION FOR PERMIT TO APPROPRIATE SURFACE WATER THIS SECTION IS NOT TO BE FILLED IN BY APPLICANT

} THE STATE OF WYOMING

STATE ENGINEER'S OFFICE

SS.

Filing/Priority Date

This instrument was received and filed for record on the _______ day of _____________________________________, _________, at _________ o'clock ________ M.

____________________________________________________ State Engineer

Recorded in Book _____________________ of Stock Reservoir Permits, on Page_____________________

Fee Paid $ _____________ Map Filed ___________ WATER DIVISION NO. _______ DISTRICT NO. ________ TEMPORARY FILING NO.______________________________

PERMIT NO.__________________STOCK RESERVOIR

NAME OF FACILITY THE ______________________________________________________________________________ STOCK RESERVOIR 1. Name(s), mailing address and phone no. of applicant(s) is/are ____________________________________________________

______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________

(if more than one applicant, designate one to act as Agent for the others)

2. Name & address of agent to receive correspondence and notices ___________________________________________________ ______________________________________________________________________________________________________ __________________________________________________ E-mail address: ______________________________________

3. The use to which the water is to be applied is in-place stock watering purposes. 4. (a) The area of the high water line of the reservoir is___________ acres. (If a pipeline to additional points of storage will be used,

include form SW4-A.)

(b) The capacity of the reservoir is __________________ acre-feet. (c) Body of Reservoir: Length _____________________ Width _____________ Average Depth _______________ (d) If enalrgement, the capacity of this enlargement is __________________________ acre-feet. 5. The source of the proposed appropriation is___________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ 6. The outlet of the reservoir is located in _______________________ of Section ______________________________________, T._______________., R._____________. Surveyed corner tie, if available: bearing ________________________________ feet distant from the ________________________________ corner of Section _________, T. __________ ., R. __________ . Lot __________ Block _____________ Subdivision Name ______________________________________________________ Latitude (Decimal Degrees) ___________________________ Longitude (Decimal Degrees) ___________________________ 7. Are any of the lands covered by the proposed reservoir owned by the State or Federal government? If so, describe lands and designate whether State or Federally owned. ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ 8. Fill out either (a) or (b). (a) The reservoir is located in the channel of _________________________________________________________________ (b) The reservoir is to be filled through the __________________________________________________________________ Canal, which has a carrying capacity of __________ cubic feet per second (c.f.s.) 9. (a) The dam is to be constructed as follows ___________________________________________________________________ _______________________________________________________contents = ___________________________ cubic yards. (b) The water face of the dam is to be protected from wave action in the following manner: ____________________________ _____________________________________________________________________________________________________ (c) Dam Height _________________________feet. 10. The accompanying map is prepared in accordance with the State Engineer's Rules and Regulations for filing applications and is hereby declared a part of this application. 11. The estimated time required for completion of construction is____________________________________________________

Permit No. __________________________Stk. Res.

Page No. _________________ (Leave Blank)

MAP AND PLANS OF PROPOSED__________________________________________________________ STOCK RESERVOIR

R.

W.

T. DETAILS OF DAM

N.

LOCATION MAP--Scale 1"=2,000 ft. SEE NOTE BELOW

FREEBOARD ABOVE HIGH WATER LINE ___________

TOP OF DAM ELEV. = _______________

HIGH WATER LINE ELEV. =

TOP WIDTH

____ :1 SLOPE ____ - INCH OUTLET PIPE

TOTAL HEIGHT _______ ____:1 SLOPE

CROSS-SECTION OF DAM--No Scale

?VALVE

AREA MAP--SCALE:--1"= __________________ (Use as large a scale as possible)

PROFILE OF DAMSITE (Looking Upstream) - Scale: Ver. 1"=20'; Hor. 1"= _________.

Capacity = [Area x Depth ? 3] = ______________________________ Acre-Feet. Existing Capacity = ____________ Acre-Feet

NOTE: The location map shown above is not required if the application is accompanied by an aerial photograph or a U.S.G.S. quadrangle map, prepared in accordance with the State Engineer's Rules and Regulations . However, the area map, cross-section of dam, profile of damsite and capacity computation must be completed in all applications.

DECLARATION Under penalties of perjury, I declare that I have examined this application and the information contained herein, and to the best of my knowledge and belief it is true, correct and complete, and that the location of the proposed facility is accurately shown either above or on the aerial photograph or U.S.G.S. quadrangle map accompanying this application.

______________________________________________________________

Signature of Applicant or Agent

_________________________________

Date

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