Easement Application Form Across State Land or Waterbody /dsl Date Received: (West of the Cascade Crest) WESTERN REGION Department of State Lands 775 Summer Street NE, Suite 100 Salem, OR 97301-1279 503-986-5200 FAX: 503-378-4844 Mail completed application with the non-refundable application fee, made payable to Oregon Department of State Lands. We accept Visa & Master Card; please call (503) 986-5200 (East of the Cascade Crest) EASTERN REGION Department of Lands 1645 NE Forbes Rd, Suite 112 Bend, OR 97701 541-388-6112 FAX: 541-388-6480 For Office Use Only: AGENCY WILL ASSIGN NUMBER Oregon Department of State Lands Application No.________ Please indicate Existing: Oregon Department of State Lands Application No._______ - APPLICANT INFORMATION Applicant is: Private Facility Government Entity PUC Regulated Utility Person Applicant’s Name and Address: Home Business Fax: Co-Applicant’s Name and Address: Home Phone: Business Fax: Email: Authorized Agent’s Name and Address: Home Phone: Business Phone: Fax: Riparian Property Owner Name and Address: (vested); if different than applicant Home Phone: Business Phone: Fax: Email: - PROJECT LOCATION Street, Road or other descriptive location Legal Description Township Section Quarter In or Near (City or Town) County Tax Map # Tax Lot # Waterway River Mile County Property Tax Account Number
A street or highway location map with road directions to the site from the nearest main highway or road. Assessor map that contains the riparian uplands. Do not mark on this map. A copy of the current year’s property tax statement which identifies the present owner’s name(s), land values, land size and tax account numbers of the riparian uplands. A legal description of the requested easement area with an accurate delineation of the area relative to the tax lot boundaries of the upland parcel. (The department may require a survey for this purpose). A separate drawing to scale of all existing and proposed structures for the easement area. Label each separate activity type stated in Section 3 and show the dimensions of each area by length and width, as stated in Section 3. Non-refundable application fee of $125.00 for water pipeline and associated fixtures or $750.00 for all other easement requests. - APPLICANT SIGNATURE I hereby request a state authorization for (number) years. (The maximum easement term is 30 years. The Department may issue permanent easements for qualifying uses. Application is hereby made for the activities described herein. I certify that I am familiar with the information contained in the application, and, to the best of my knowledge and belief, this information is true, complete, and accurate. I further certify that I possess the authority to undertake the proposed activities. I understand that the granting of other permits by local, county, state or federal agencies does not release me from the requirement of obtaining the authorization requested before commencing the project. I understand that payment of the required state application fee does not guarantee authorization. Print /Type Name Title ____________ Applicant Signature Date I appoint the person named below to act as my duly authorized agent. Print /Type Name Title ____________ Authorized Agent Signature Date