1. Name and address of the person making the discharge: 

Home Phone: 

Work Phone: 

2. Location of the discharge (in township, range and section, 1/4, 1/4, 1/4, if available):

3. The means of discharge (to a lagoon, flowing stream, water course, arroyo, septic tank-leachfield, other) - specify:

4. The estimated concentration of contaminants in the discharge:

5. The type of operation from which the discharge is derived:

6. The estimated flow to be discharged per day:

7. The estimated depth to ground water:

Applicant Signature:

Date: 

Note: Electronic returns DO NOT apply as submitted applications. The completed and signed application form must be returned to one of the addresses below.

For discharges to any surface water source, submit a completed copy of this form to:

For discharges to any ground water source, submit a copy of this form to: