Name of Water Right Claimant *

(Claimant name should be the same name as on previously submitted Statement of Diversion and Use)

Landowner or Authorized Representative:
Contact First Name *

Contact Last Name *

Mailing Street Address *

City *

State *

Zip Code *

Email Address *

Phone Number *

Please fill out a separate form for each diversion:
SWRCB Statement Number for this water right claim *

SWRCB License Number for this claim (if applicable)

Reclamation District number

Type(s) of water right (check all that apply) *:
RiparianLicensePre-1914Other

Other (explain)

Method of diversion and measurement *:
Staff gaugeDitch gateMetered siphonMetered pumpUnmetered siphonUnmetered pumpOther

Other (explain)

Is there a meter at the point of diversion? *
YesNo

Model type

Can it log data digitally or does it have a counter?

Is power available at the point of diversion? *
YesNo

Power type

Volts

Is the point of diversion shared with other users? *
YesNo

If yes, please list other user name(s) and S0 number(s), if known. (Separate multiple names and numbers with commas):
Names

SWRCB Statement Number(s)

Assessor's Parcel Number(s) (APN) served by the water right claim associated with the Statement of Diversion and Use listed above:

(1) County APN *

(1) Primary Crop *

(1) Irrigation Method *

(1) Number of acres *

(2) County APN

(2) Primary Crop

(2) Irrigation Method

(2) Number of acres

(3) County APN

(3) Primary Crop

(3) Irrigation Method

(3) Number of acres

(4) County APN

(4) Primary Crop

(4) Irrigation Method

(4) Number of acres

(5) County APN

(5) Primary Crop

(5) Irrigation Method

(5) Number of acres

(If you have additional APNs, please fill out a separate form.)

Point of Diversion *

Direct Diversion Amount *

Direct Diversion Unit *
(Gallons or acre-feet)

Please attach an aerial map/photograph (e.g., farm subsidy map or Google Earth image) of the area served by the claimed water right, showing the diversion location. This should be the same as what was provided to the SWRCB for your initial Statement of Diversion and Use.

I understand that the grant of an extension of time to comply with the measurement regulation does not change the responsibility for filing the annual water use report due by June 30 of each year. On behalf of the subject water right claim, I acknowledge individual responsibility to submit the annual use report. During the period of this extension of time, water use under the above-referenced claim will be estimated and reported in good faith, based on current practices and any interim improvement of such practices.

In connection with the exercise of the above-referenced claim(s), I am also aware of the responsibility to comply with the measurement regulation by January 1, 2017. Following diligent effort to comply with the regulation, I have determined that compliance by January 1, 2017 is not possible because of obstacles presented by the specific circumstances of the applicable point of diversion for the subject water right claim(s) within the Delta (tidal gate, siphon, fouling/corrosion potential, unreliability of available devices, etc.). Further, I have learned that a variety of measurement devices installed by others have failed under harsh Delta conditions. Therefore, I have decided to join the The Freshwater Trust program of experimentation described in the attached request for extension of time. I anticipate that the program of experimentation will identify practical devices, methods or alternatives for fully complying with the measurement regulation. I also understand that I am solely responsible for compliance with the measurement regulation regardless of whether The Freshwater Trust program remains in place. The Freshwater Trust is hereby designated as representative of the above-referenced claim(s) before the Delta Watermaster as to any matter related to this request for extension of time.

Check here if you accept these terms.
Signature

Date