Affidavit For The Partial Abandonment Of A Ground Water Certificate Of Registration Form - Oregon
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1AFFIDAVIT FOR THE PARTIAL ABANDONMENT OF A
GROUND WATER CERTIFICATE OF REGISTRATION
State of Oregon
)
) ss
County of ____________________________
)
I/We (or authorized agent), _____________________________________________________________,
residing at ___________________________________________________________________________,
telephone number _____________________________________, being first duly sworn depose and say:
1. I/We are the legal and deeded owner(s) of the property described as tax lot number _____________, within
the
___¼ ___¼, Section ___, Township ____ N/S, Range ____ E/W, of the Willamette Meridian, in
__________________________________ County, Oregon, as shown on the attached map and described in
the attached deed and legal description and made part of this affidavit;
2. Ground Water Certificate of Registration number _____________ in the name of _____________________,
with a tentative date of priority of ____________________ for use of ________ gpm/cfs/AF for the purpose
of __________________________ (use) is appurtenant to my/our property;
3. The appurtenant ground water registration is/is not located within the boundaries of an irrigation, drainage,
water improvement, or water control district, or federal reclamation project (if the registration is located
within a district or reclamation project, name it here:
________________________________________________); and
4. I/We have abandoned any and all interest in the portion of this ground water registration shown on the
attached map and described as follows:
Theclaim to the use of _______ gpm/cfs/AF for _______________________________, located:
(use)
____¼ ____¼
______ Acres
____¼ ____¼
______ Acres
____¼ ____¼
______ Acres
Section ____
Township ____ N/S, Range ____E/W, WM; and
5. I/We have abandoned any and all claim to appropriate and use ground water as described above under this
certificate of registration for the purpose of the final determination of the right to appropriate ground water
under ORS 537.670 to 537.695
___________________________________
_______________________
Signature of legal owner as listed on deed, or authorized agent
Date
___________________________________
_______________________
Signature of legal co-owner as listed on deed
Date
(If applicable)
Subscribed and Sworn to Before Me this _______ day of _____________________, 200___.
____________________________________
Notary Public for Oregon
My Commission Expires ___________________
PLEASE ATTACH A LEGIBLE COPY OF: 1) A DEED WHICH LISTS LAND OWNERS AND INCLUDES A LEGAL
DESCRIPTION OF AFFECTED LANDS, AND 2) A COPY OF THE GROUND WATER REGISTRATION MAP OR A TAX LOT
MAP WITH THE ABANDONED GROUND WATER APPROPRIATION CLEARLY DRAWN AND IDENTIFIED. IF ACTING AS
AN AUTHORIZED AGENT, INCLUDE COPY OF POWER OF ATTORNEY OR OTHER DOCUMENTS GRANTING AUTHORITY
TO ACT ON BEHALF OF LEGAL OWNER(S).
March
2007
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