Form 55-73 Landowner Authorization to Register a Well of Record in a Third Party's Name - Arizona

Form 55-73 or the "Landowner Authorization To Register A Well Of Record In A Third Party's Name" is a form issued by the Arizona Department of Water Resources.

Download a PDF version of the Form 55-73 down below or find it on the Arizona Department of Water Resources Forms website.

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Arizona Department of Water Resources
Groundwater Permitting and Wells Section
Landowner Authorization to
3550 N. Central Ave., Phoenix, AZ 85012-2105
Register a Well of Record in a
(602) 771-8527 -- (602) 771-8690 fax
Third Party’s Name
· www.water.az.gov ·
FILE NUMBER
WELL REGISTRATION NUMBER
55 -
The Arizona Department of Water Resources (ADWR) requires written permission from a landowner to register
a well on the landowner’s parcel to a third party. Landowners, or their designated representative, must
authorize the change on a Request to Change Well Information (form 55-71A) or this form.
PARCEL ADDRESS:_____________________________________________________________________
COUNTY PARCEL ID
_______ -
________ - ________
COUNTY _____________________
BOOK
MAP
PARCEL
In accordance with ADWR policy, I certify that:
I am the owner of the parcel referenced above, for which I am giving permission to a third party to be listed as
the registered well owner.
I am an authorized representative of the owner the parcel referenced above, for which I am giving permission to
a third party to be listed as the registered well owner.
SIGNATURE
TYPE OR PRINT NAME OF LANDOWNER / REPRESENTATIVE
TITLE
SIGNATURE
DATE SIGNED
PRINT FORM
SAVE FORM
Reset Entire Form
55-73 Landowner Authorization to Register a Well in a Third Party’s Name (Rev 20160218)
Page 1
Reset Entire Form First
Arizona Department of Water Resources
Groundwater Permitting and Wells Section
Landowner Authorization to
3550 N. Central Ave., Phoenix, AZ 85012-2105
Register a Well of Record in a
(602) 771-8527 -- (602) 771-8690 fax
Third Party’s Name
· www.water.az.gov ·
FILE NUMBER
WELL REGISTRATION NUMBER
55 -
The Arizona Department of Water Resources (ADWR) requires written permission from a landowner to register
a well on the landowner’s parcel to a third party. Landowners, or their designated representative, must
authorize the change on a Request to Change Well Information (form 55-71A) or this form.
PARCEL ADDRESS:_____________________________________________________________________
COUNTY PARCEL ID
_______ -
________ - ________
COUNTY _____________________
BOOK
MAP
PARCEL
In accordance with ADWR policy, I certify that:
I am the owner of the parcel referenced above, for which I am giving permission to a third party to be listed as
the registered well owner.
I am an authorized representative of the owner the parcel referenced above, for which I am giving permission to
a third party to be listed as the registered well owner.
SIGNATURE
TYPE OR PRINT NAME OF LANDOWNER / REPRESENTATIVE
TITLE
SIGNATURE
DATE SIGNED
PRINT FORM
SAVE FORM
Reset Entire Form
55-73 Landowner Authorization to Register a Well in a Third Party’s Name (Rev 20160218)
Page 1

Download Form 55-73 Landowner Authorization to Register a Well of Record in a Third Party's Name - Arizona

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