Form OLWR-AP-21 "Application for Permit to Divert or Withdraw for Beneficial Use the Public Waters of the State of Mississippi" - Mississippi

What Is Form OLWR-AP-21?

This is a legal form that was released by the Mississippi Department of Environmental Quality - a government authority operating within Mississippi. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2021;
  • The latest edition provided by the Mississippi Department of Environmental Quality;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form OLWR-AP-21 by clicking the link below or browse more documents and templates provided by the Mississippi Department of Environmental Quality.

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Download Form OLWR-AP-21 "Application for Permit to Divert or Withdraw for Beneficial Use the Public Waters of the State of Mississippi" - Mississippi

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APPLICATION FOR PERMIT TO DIVERT OR WITHDRAW
FOR BENEFICIAL USE THE PUBLIC WATERS OF THE STATE OF MISSISSIPPI
DEPARTMENT OF ENVIRONMENTAL QUALITY, OFFICE OF LAND AND WATER RESOURCES
P.O. BOX 2339, JACKSON, MS 39225-2339; (601) 961-5202
FORM OLWR-AP-21 (REV 05/21)
This box is for office use only
Permit No.
Issued:
Reissue Date:
Expires:
«Permit_Number»
Lat:
Long:
Elev:
Quad:
Permit No. of Replaced Well:
Aquifer:
FIP Well No.
STAC:
Basin No.
DOH No.
Dam Inv. No.
Hazard Class:
DS Approval/Date:
RENEWAL – PERMIT NO. _______________________
THIS APPLICATION IS FOR
(Circle one): NEW PERMIT
REPLACEMENT
MODIFICATION
(Circle one): GROUNDWATER – COMPLETE SECTIONS A, B, D
THIS APPLICATION IS FOR
SURFACE WATER – COMPLETE SECTIONS A, C, D, E
BENEFICIAL USE
(Circle one or more):
1) Public Water System
2) Irrigation
3) Industrial
4) Fish Culture
5) Recreation
6) Institutional (e.g. Church, School) 7) Commercial (e.g. Hotel, Casino, Restaurant)
8) Fire Protection
9) Livestock
10) Flood Protection
11) Wildlife Management 12) Other: _____________________________________
ARE YOU REQUESTING STANDBY STATUS
: YES NO (Standby status does not allow for withdrawal of groundwater.)
SECTION A
(REQUIRED)
LANDOWNER: __________________________________________________
____________________________
(Name)
(E-mail address)
___________________________________________________________________________________________
(Address)
_______________________________________________ _____________________
__________________
(City)
(State & Zip)
(Telephone No.)
(Mobile No.)
APPLICANT, AGENT OR LESSEE
(if different from Landowner):
_______________________________________________________
________________________________
(Name)
(E-mail address)
___________________________________________________________________________________________
(Address)
_______________________________________________ _____________________
__________________
(City)
(State & Zip)
(Telephone No.)
(Mobile No.)
LOCATION of diversion/withdrawal point
(A suitable map with location marked MUST accompany this application):
Latitude: ____________________ Longitude: ____________________ (Decimal degrees with at least four significant digits)
(Example: Latitude: 32.3065, Longitude: -90.1784)
______ ¼ of the _______ ¼ of Section ________ , Township _______ , Range _______ , County ______________________
Does the land to which this application pertains have any source(s) of water other than that for which you are now applying (circle one)? YES NO
If yes, describe the nature and amount of any additional supply and, if applicable, list permit number. ______________________________________
(CONTINUED ON BACK)
Page 1 of 3
APPLICATION FOR PERMIT TO DIVERT OR WITHDRAW
FOR BENEFICIAL USE THE PUBLIC WATERS OF THE STATE OF MISSISSIPPI
DEPARTMENT OF ENVIRONMENTAL QUALITY, OFFICE OF LAND AND WATER RESOURCES
P.O. BOX 2339, JACKSON, MS 39225-2339; (601) 961-5202
FORM OLWR-AP-21 (REV 05/21)
This box is for office use only
Permit No.
Issued:
Reissue Date:
Expires:
«Permit_Number»
Lat:
Long:
Elev:
Quad:
Permit No. of Replaced Well:
Aquifer:
FIP Well No.
STAC:
Basin No.
DOH No.
Dam Inv. No.
Hazard Class:
DS Approval/Date:
RENEWAL – PERMIT NO. _______________________
THIS APPLICATION IS FOR
(Circle one): NEW PERMIT
REPLACEMENT
MODIFICATION
(Circle one): GROUNDWATER – COMPLETE SECTIONS A, B, D
THIS APPLICATION IS FOR
SURFACE WATER – COMPLETE SECTIONS A, C, D, E
BENEFICIAL USE
(Circle one or more):
1) Public Water System
2) Irrigation
3) Industrial
4) Fish Culture
5) Recreation
6) Institutional (e.g. Church, School) 7) Commercial (e.g. Hotel, Casino, Restaurant)
8) Fire Protection
9) Livestock
10) Flood Protection
11) Wildlife Management 12) Other: _____________________________________
ARE YOU REQUESTING STANDBY STATUS
: YES NO (Standby status does not allow for withdrawal of groundwater.)
SECTION A
(REQUIRED)
LANDOWNER: __________________________________________________
____________________________
(Name)
(E-mail address)
___________________________________________________________________________________________
(Address)
_______________________________________________ _____________________
__________________
(City)
(State & Zip)
(Telephone No.)
(Mobile No.)
APPLICANT, AGENT OR LESSEE
(if different from Landowner):
_______________________________________________________
________________________________
(Name)
(E-mail address)
___________________________________________________________________________________________
(Address)
_______________________________________________ _____________________
__________________
(City)
(State & Zip)
(Telephone No.)
(Mobile No.)
LOCATION of diversion/withdrawal point
(A suitable map with location marked MUST accompany this application):
Latitude: ____________________ Longitude: ____________________ (Decimal degrees with at least four significant digits)
(Example: Latitude: 32.3065, Longitude: -90.1784)
______ ¼ of the _______ ¼ of Section ________ , Township _______ , Range _______ , County ______________________
Does the land to which this application pertains have any source(s) of water other than that for which you are now applying (circle one)? YES NO
If yes, describe the nature and amount of any additional supply and, if applicable, list permit number. ______________________________________
(CONTINUED ON BACK)
Page 1 of 3
SECTION B
(to be completed for GROUNDWATER SOURCE)
AQUIFER:_________________________________
MS DEPARTMENT OF HEALTH NO.:_______________
1.
DESCRIPTION
2.
of completed well:
Driller:_____________________________________________
Date completed: __________________________________
Under whose name was well originally drilled (if known)? _________________________________________________________
Depth of well: ________________________ feet
Surface Casing: Length ________________ feet; Diameter ________ inches; Type __________________________________
(PVC, steel, stainless, black iron, other)
Screen: Length _______________________ feet; Diameter ________ inches; Type __________________________________
(PVC, steel, stainless, open hole, other)
Pump: Type ____________________________________ ; Capacity ________________ ;
(submersible, turbine, other)
(gallons per minute)
Power unit: Type _____________________________________________ ; Size _____________________________ horsepower
(electric, tractor, diesel, gasoline, butane, other)
LOCAL WELL NAME:
_________________________________________________
PERMITTED VOLUME:
3.
(a) ____________________________ acre-feet per year at a maximum of _________________________________ gallons per minute
(b) ____________________________ million gallons per date at a maximum rate of ________________________ gallons per minute
SECTION C
(to be completed for SURFACE WATER SOURCE)
SOURCE
1.
of water is from _____________________________
which drains into ___________________________________
which drains into _________________________________________________________________________________________
(major stream or river)
2. DESCRIPTION
of pump/diversion works:
Pump: Type ________________________________ ; Diameter __________ inches; Capacity _____________ gallons per minute
(turbine, jet, other)
Power Unit: Type _______________________________ ; Size ________________ horsepower
(electric, tractor, diesel, gasoline, butane, other)
3. PERMITTED VOLUME
____________________________ acre-feet per year at a maximum of _________________________________ gallons per minute
SECTION D
WATER USE DATA (REQUIRED – complete sections related to beneficial use)
IRRIGATION
1.
: List the number of acres of each crop to be irrigated: Rice ______ ; Cotton __________ ; Oats ____________ ;
Corn ________ ; Soybeans ________ ; Pasture ________ ; Truck ________ ; Wheat ________ ; Grain Sorghum ________ ;
Wildlife ____________ ; Other (specify) _____________________________________________________________ total acres
(a) Method of Irrigation (circle one) –
Center Pivot
Flood
Furrow
(b) Land Condition (circle one) -
Precision Land Formed
Smoothed
(c) ASCS Farm No. __________________________ Tract No. ___________________________________________________
(CONTINUED ON NEXT PAGE)
Page 2 of 3
FISH CULTURE:
2.
Explain how water will be used: ____________________________________________________________
_______________________________________________________________________ ; Reservoir acreage _______________
PUBLIC WATER SYSTEM
3.
Choose “a” or “b”. (a) The number of people served is _____________ or (b) The number of connections is ______________ .
INDUSTRIAL:
4.
If the water is released into a watercourse, indicate the amount released each year __________________ (MGD)
Rate of release ____________________________ (MGD); NPDES Permit No. ______________________________________
Explain any changes in quality of water to be released: ____________________________________________________________
Explain how water will be used: ______________________________________________________________________________
How much groundwater will be used for once-through non-contact cooling? ___________________________________________
RECREATION:
5.
Explain how water will be used:______________________________________________________________
________________________________________________________________________________________________________
OTHER USE:
6.
Explain in detail (if needed, attach another page): __________________________________________________
________________________________________________________________________________________________________
REMARKS:
7.
____________________________________________________________________________________________
________________________________________________________________________________________________________
SECTION E
(to be completed for SURFACE WATER IMPOUNDMENTS (DAMS) on continuously flowing streams)
1. Name of storage reservoir: _____________________________________________
Dam Height _______________ feet
2. Surface area at normal pool: ____________________ Storage capacity at normal pool: _____________________ acre-feet
Additional Contact Information (Agent, etc.):
_________________________________________________
The ACCOMPANYING MAP is hereby declared a part of
this application. The TEN DOLLAR ($10.00) permit fee is
(Name)
enclosed herewith.
_________________________________________________
I hereby attest that I am duly authorized and have legal
(Title)
capacity to execute and deliver this application and the
_________________________________________________
information provided is accurate to the best of my ability.
(Address)
_________________________________________________
_________________________________________________
(City, State, ZIP)
(Print Name)
_______________________ ________________________
_________________________________________________
(Telephone)
(Mobile)
(Title)
_______________________________________________________
_________________________________________________
(E-mail address)
(Signature/Date)
Page 3 of 3
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