ARIZONA DEPARTMENT OF WATER RESOURCES
GROUNDWATER PERMITTING AND WELLS UNIT
MAIL TO: P.O. BOX 36020, PHOENIX, ARIZONA 85067-6020
1110 W. Washington St. Suite 310, Phoenix, Arizona 85007-2952
Phone (602) 771-8527 Fax (602) 771-8590
APPLICATION FOR PERMIT TO USE WATER TO FILL OR REFILL A BODY OF
WATER WITHIN AN ACTIVE MANAGEMENT AREA,
PURSUANT TO A.R.S. § 45-132 THROUGH A.R.S. § 45-134.
I.
INSTRUCTIONS:
FOR DEPARTMENT USE ONLY
1.
This application should be used to obtain a permit to fill or refill
Application/Permit No.
a body of water in an Active Management Area for landscape,
Filed
recreation, or scenic purposes.
AMA
2.
Complete all appropriate items on this application and sign in
the designated place.
S/B
W/S
3.
Mail to P.O. Box 36020, Phoenix, AZ 85067-6020 or deliver in
person to 3550 North Central Avenue, Phoenix, Arizona 85012.
4.
The initial fee for a Permit to Use Groundwater to Fill or Refill a Body of Water is $1,000. Total fees for this
application are based upon an hourly billable rate, which can be found on the ADWR web site @www.azwater.gov.
If the costs of reviewing your application exceed $1,000, you will be invoiced for the difference, up to a maximum
total fee of $10,000. Payment may be made by cash, check, or credit card (if you wish to pay by credit card, please
contact the Groundwater Permitting and Wells Program at 602-771-8527). Checks should be made payable to the
Arizona Department of Water Resources. In addition to the hourly application fee, the applicant must pay any
review-related costs associated with the application and the actual cost of mailing or publishing any legal notice of
the application or notice of a pre-decision administrative hearing on the application. Review-related costs are: (1)
costs associated with a pre-decision hearing on the application, such as court reporter services and facility rentals
for the hearing, and (2) mileage expenses for a site visit conducted before issuing a decision on the application.
Failure to enclose the initial application fee will cause the application to be returned. Fees for a Permit to Use
Groundwater to Fill or Refill a Body of Water are authorized by A.R.S. § 45-133 and A.A.C. R12-15-103.
II. GENERAL DATA
1.
Name of Applicant
Mailing Address
City
State
Zip
Contact Person
Telephone Number
E-mail address
2.
Type of permit (check):
Poor Quality Exemption (§ 45-132)
Initial Interim Use (§ 45-133)
Renewal of Interim Use Permit (§ 45-133) Existing Permit No. 59-
Temporary, Emergency Use (§ 45-134)
3.
Location of body of water
¼
¼
¼, Section
Township
N/S, Range
E/W
AMA
4.
Amount of water to be used for:
Poor Quality or Temporary/Emergency Permit is
acre feet per year.
Interim Use Permits/Renewals: Year #1 (Initial Fill) ____________(AF)
DWR 45-132 Revised 7/2016
ARIZONA DEPARTMENT OF WATER RESOURCES
GROUNDWATER PERMITTING AND WELLS UNIT
MAIL TO: P.O. BOX 36020, PHOENIX, ARIZONA 85067-6020
1110 W. Washington St. Suite 310, Phoenix, Arizona 85007-2952
Phone (602) 771-8527 Fax (602) 771-8590
APPLICATION FOR PERMIT TO USE WATER TO FILL OR REFILL A BODY OF
WATER WITHIN AN ACTIVE MANAGEMENT AREA,
PURSUANT TO A.R.S. § 45-132 THROUGH A.R.S. § 45-134.
I.
INSTRUCTIONS:
FOR DEPARTMENT USE ONLY
1.
This application should be used to obtain a permit to fill or refill
Application/Permit No.
a body of water in an Active Management Area for landscape,
Filed
recreation, or scenic purposes.
AMA
2.
Complete all appropriate items on this application and sign in
the designated place.
S/B
W/S
3.
Mail to P.O. Box 36020, Phoenix, AZ 85067-6020 or deliver in
person to 3550 North Central Avenue, Phoenix, Arizona 85012.
4.
The initial fee for a Permit to Use Groundwater to Fill or Refill a Body of Water is $1,000. Total fees for this
application are based upon an hourly billable rate, which can be found on the ADWR web site @www.azwater.gov.
If the costs of reviewing your application exceed $1,000, you will be invoiced for the difference, up to a maximum
total fee of $10,000. Payment may be made by cash, check, or credit card (if you wish to pay by credit card, please
contact the Groundwater Permitting and Wells Program at 602-771-8527). Checks should be made payable to the
Arizona Department of Water Resources. In addition to the hourly application fee, the applicant must pay any
review-related costs associated with the application and the actual cost of mailing or publishing any legal notice of
the application or notice of a pre-decision administrative hearing on the application. Review-related costs are: (1)
costs associated with a pre-decision hearing on the application, such as court reporter services and facility rentals
for the hearing, and (2) mileage expenses for a site visit conducted before issuing a decision on the application.
Failure to enclose the initial application fee will cause the application to be returned. Fees for a Permit to Use
Groundwater to Fill or Refill a Body of Water are authorized by A.R.S. § 45-133 and A.A.C. R12-15-103.
II. GENERAL DATA
1.
Name of Applicant
Mailing Address
City
State
Zip
Contact Person
Telephone Number
E-mail address
2.
Type of permit (check):
Poor Quality Exemption (§ 45-132)
Initial Interim Use (§ 45-133)
Renewal of Interim Use Permit (§ 45-133) Existing Permit No. 59-
Temporary, Emergency Use (§ 45-134)
3.
Location of body of water
¼
¼
¼, Section
Township
N/S, Range
E/W
AMA
4.
Amount of water to be used for:
Poor Quality or Temporary/Emergency Permit is
acre feet per year.
Interim Use Permits/Renewals: Year #1 (Initial Fill) ____________(AF)
DWR 45-132 Revised 7/2016
Calculation: ___________________ X ________________ + volume of water to fill the lake ___________
(surface area of the lake)
(evaporation rate)
Year #2
Year #3
Year #4
Year #5
5.
Right to source water:
Poor quality water
Authority to withdraw groundwater
Groundwater
Type 1 Non-irrigation Grandfathered Right No.
Type 2 Non-irrigation Grandfathered Right No.______________________________
Other:
Surface Water
Permit or Certificate of Water Right No:
Decreed Right :
Name of water distributor:
Address
Other sources of water
6. For poor quality water:
a.
Attach evidence proving no other beneficial use exists for the water and evidence of economic feasibility of
transporting the water for beneficial use.
b.
Attach demonstration of management plan consistency.
c.
Attach plan or proposal for monitoring.
d.
What source will be used to fill or refill the body of water once water is determined to no longer be of poor quality
without treatment?
7. For initial interim use permit or renewal of an interim use permit:
a.
Estimate of time required for effluent to be available to fill or refill the body of water
(Months).
b.
Provide easements for the on-site treatment facility or proof of access to an off-site treatment facility and for
transportation of a permanent effluent supply.
c.
Provide name and location of treatment facility.
d.
Provide evidence of Arizona Department of Environmental Quality (ADEQ) approval for on-site treatment facility.
e.
Provide a copy of the recorded easements and the on-site treatment facility, if any, on the plat of record for the
subdivision or development where the lake is located.
f.
Describe the means of transporting effluent from the treatment facility to the body of water.
g.
Provide plans demonstrating evidence that the body of water will be used to store effluent, which well be used for
landscaping of common areas or other beneficial purposes which otherwise would have required groundwater or
surface water.
h.
Provide a copy of a conservation program showing consistency with the management plan.
8. For temporary, emergency use:
a.
Provide evidence demonstrating that an emergency exists because of a threat to public health and welfare.
b.
Previous temporary, emergency Permit No:
c.
Describe actions owner took to reasonably prevent circumstances leading to issuance of previous temporary,
emergency permit.
d.
Attach plan for monitoring.
DWR 45-132 Revised 7/2016
9. A permit is requested for
days
months
years
I (we)
hereby affirm that all information provided in
this application is true and correct to the best of my/our knowledge and belief.
Applicant’s Signature
(Date)
Landowner’s Signature (If different from Applicant)
(Date)
NOTICE
A.R.S. § 41-1030(B), (D), (E) and (F) provide as follows:
B.
An agency shall not base a licensing decision in whole or in part on a licensing requirement or condition that is not specifically authorized by statute, rule
or state tribal gaming compact. A general grant of authority in statute does not constitute a basis for imposing a licensing requirement or condition unless a rule is
made pursuant to that general grant of authority that specifically authorizes the requirement or condition.
D.
This section may be enforced in a private civil action and relief may be awarded against the state. The court may award reasonable attorney fees, damages
and all fees associated with the license application to a party that prevails in an action against the state for a violation of this section.
E.
A state employee may not intentionally or knowingly violate this section. A violation of this section is cause for disciplinary action or dismissal pursuant
to the agency’s adopted personnel policy.
F.
This section does not abrogate the immunity provided by section 12-820.01 or 12-820.02.
DWR 45-132 Revised 7/2016