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2 Designation or Modification of D REV DESIGNATION OR MODIFICATION OF DESIGNATION OF ASSURED WATER SUPPLY APPLICATION PART A - GENERAL INFORMATION 1. This is an application for: New Designation Modification of an existing Designation If this is a modification of an existing designation, you may expressly reference items submitted in support of a previous application rather than resubmitting identical items. However, please provide updated documentation if more recent information is available. 2. Name of municipal provider:_______________________________________ AMA: ___________________________ ADWR No. 56-_______________________________________County:_________________________________________ E-Mail: Phone: Fax: E-Mail: Name and address of person representing the municipal provider: Name: Title:__ _ Address: Contact person for questions regarding this application: Name: Company: Address: Phone: Fax: 5. If not already on file with the Department, provide a map of the service area that includes the current and proposed distribution system and any treatment or storage facilities and reference as an attachment. Up-to-date service area map on file with the Department Hard copy of service area map attached Attachment: ___________________________ Electronic copy of service area map attached Attachment: ___________________________ I DO HEREBY certify that the information contained in this application and all information accompanying it is true and correct to the best of my knowledge and belief. NOTE: If the applicant is a city or town, include a resolution of the governing body of the city or town authorizing the person to sign the application. Printed Name Title Signature Date ARIZONA DEPARTMENT OF WATER RESOURCES OFFICE OF ASSURED AND ADEQUATE WATER SUPPLY PHOENIX, ARIZONA 850 (602) 771-8599 Fax: (602) 771-8689 assuredadequate@azwater.gov DATE RECEIVED: APPLICATION NO: 3 PART B - DEMAND ESTIMATE Please use the Designation demand spreadsheet provided by the Department to document the estimated water demand in the service area. See http://www.azwater.gov and click on Permits / Reporting to download a copy of the Designation demand spreadsheet OR provide a detailed explanation of the assumptions used in estimating the water demand for the water service area and reference the demand spreadsheet and/or the assumptions used as an attachment and complete Table B below. Attachment:____________________________________________. Requested Term of Designation: ________________________________________ (not less than two years after issuance). CURRENT ANNUAL DEMAND: acre-feet per year YEAR: _____________________________ The current demand is the total water production for the most recent completed calendar year. This includes both potable and non-potable water sources, as well as water that is lost or unaccounted for. COMMITTED DEMAND: _________________________ acre-feet per year The committed demand is the estimated demand for recorded, but unbuilt lots within the water service area. PROJECTED DEMAND: _________________________ acre-feet per year YEAR: _____________________________ The projected demand is the demand, at build-out, of lots that will be recorded and other customers expected to be added during the term of the designation. The projected demand should equal the difference between the total amount of water projected to be delivered in the projected calendar year you are seeking to be designated through, minus the current demand. TOTAL ANNUAL DEMAND: ______________________ acre-feet per year YEAR:_____________________________ The total annual demand is the sum of the current demand, committed demand and projected demand provided above. TABLE B: SUM OF CURRENT, COMMITTED, AND PROJECTED DEMAND FOR THE WATER SERVICE AREA FOR THE CURRENT YEAR PLUS EACH SUBSEQUENT YEAR FOR THE NEXT TEN YEARS Year 1 2 3 4 5 6 7 8 9 10 Population Current Demand (af/yr) Committed demand (af/yr) Projected demand (af/yr) Total Demand (af-yr) (If proposed term of Designation is greater than 10 years, please provide this information on a separate sheet.) PART C- PHYSICAL AVAILABILITY OF SOURCE WATER 1. A comprehensive hydrologic study must be submitted with this application, unless the Department has previously reviewed the hydrologic conditions for this area and has issued a valid Letter of Water Availability, Physical Availability Determination or Analysis of Assured Water Supply. The Department has adopted a substantive policy statement to provide guidelines ebsite at http://www.azwater.gov under the Permits, Forms and Applications page. Please indicate the evidence of physical availability and reference as an attachment: 4 Water Availability Letter Physical Availability Determination New Hydrologic Study Other, please specify: Technical Registration Requirements The Arizona Department of Water Resources requires hydrologic and engineering reports, studies, drawings and maps, specifications, analyses or related data submitted to support the evaluation of this application to be signed and sealed by a professional geologist or qualified professional engineer who is registered in the State of Arizona under the authority of A.R.S. Title 32, Chapter 1. 2. If not already included in the attachment under Part C, question 1 above, please attach a list of all existing service area wells including the well registration numbers, legal description (township, range, section, 180, 40, 10 quarter sections) and pump capacity of each well in gallons per minute. If your application includes proposed wells, please provide the legal description (township, range, section, 180, 40, 10 quarter sections) of each proposed well and the anticipated pump capacity of each proposed well in gallons per minute. 3. If you had a pre-application meeting with the Department, please indicate the date of that meeting: ________________. 4. If you submitted a hydrologic study propo application, please indicate the date of submittal of the hydrologic study proposal: __________________________. PART D- CONTINUOUS AVAILABILITY AND LEGAL AVAILABILITY OF SOURCE WATER 1. If the municipal provider has not yet established a service area right, please attach a copy of the Initial Petition to Establish New Water Service Area as submitted to the AMA. 2. If applicant is a private water company, attach a copy of any Decision and Order from the Arizona Corporation Commission establishing the CC&N or extension of CC&N. Reference as attachment: _____________________________________. 3. To complete the table below, multiply the Total Annual Demand computed in Part B by 100 to obtain the 100-year demand and enter at the bottom of the chart. Enter the appropriate 100-year demands for each type of water delivered to the subdivision for each category. Source of Supply 100 Year Volume (ac-ft) Groundwater Central Arizona Project Water: Direct treatment and delivery Stored and Recovered water Surface Water: Direct treatment and delivery Stored and Recovered water Effluent: Direct treatment and delivery Stored and Recovered water Other Total 100-yr Volume 4. See A.A.C. R12-15-717 and R12-15-718 for documentation that should be submitted as evidence of continuous availability and legal availability (respectively) for each source of supply. Please reference attachment(s): 5 PART E - CONSISTENCY WITH MANAGEMENT PLAN 1. For the municipal or county jurisdiction within which the service area is located, list any water conservation ordinances and briefly describe the sections that apply to the water service area. If they will serve as evidence of your demand projections, please reference as attachment. Attachment: __________________________________________________________. 2. Generally describe any other current or proposed conservation practices, rates, fees, restrictions, policies and devices to be utilized within the service area to meet the conservation requirements of the Management Plan and reference as an attachment. Attachment: __________________________________________________________________________. NOTE: See A.A.C. R12-15-7219A). If demand estimates rely on these conservation requirements, please reference attachment: PART F - FINANCIAL CAPABILITY Please check one or more of the following and include attachments as necessary: The applicant has constructed adequate delivery, storage, and treatment works. The applicant has entered into written agreements requiring potential developers to construct adequate delivery, storage, and treatment works. Attachment: __________________________________________________________________. If the applicant is a city or town, the applicant has: Adopted a five year capital improvement plan that provides for the construction, or the commencement of construction, of adequ chief financial officer that finances are available to implement that portion of the five-year plan; or Submitted evidence demonstrating that financing mechanisms are in place to construct adequate delivery, storage, and treatment works in a timely manner. If the applicant is a private water company, the applicant has received approval from the Arizona Corporation Commission for financing the construction of adequate delivery, storage, and treatment works. PART G - CONSISTENCY WITH MANAGEMENT GOAL Please check all that apply below: Enrollment of the water provider as a member service area in the Central Arizona Groundwater Replenishment District (Phoenix, Tucson and Pinal AMAs ONLY). A separate application for membership must be filed with the Central Arizona Water Conservation District, and the membership documents must be executed and recorded before the Designation will be issued. Extinguishment of grandfathered groundwater rights dedicated to the municipal provider's water service area. Provide evidence and reference the attachment: Other. Please specify:______________________________________________________________________________ 6 PART H - WATER QUALITY 1. Are the well or wells from which water will be withdrawn by the municipal provider within one mile of a Water Quality Assurance Revolving Fund (WQARF) or Superfund site? Yes No. meet the water quality requirements in A.A.C. Title 18, Chapter 4, and reference as attachment: 2. Municipal provider is or will be regulated by the Arizona Department of Environmental Quality (ADEQ) or another governmental entity with equivalent jurisdiction. If this applies, independent proof of adequate water quality is not required, please skip to Part H. 3. If provider is currently regulated, provider is in compliance with all state and federal water quality regulations. 4. If the municipal provider serves or will serve 15 customers or less, provide current (within the last 60 days) analytical results on water samples taken from a well or wells constructed within the service area, demonstrating that the water meets the water quality requirements in A.A.C. Title 18, Chapter 4, and reference as attachment: NOTE: Information on the required water quality analyses may be found at the ADEQ website http://www.adeq.gov. PART I FEES The initial fee for an Application for a Designation of Assured Water Supply or a Modification of a Designation of Assured Water Supply is $2,000. Total fees for this application are based upon an hourly billable rate, which can be found on the ADWR web site @www.azwater.gov. If the costs of reviewing your application exceed $2,000, you will be invoiced for the difference, up to a maximum total fee of $35,000. Payment may be made by cash, check, or credit card (if you wish to pay by credit card, please contact the Office of Assured and Adequate Water Supply at 602-771-8599). Checks should be made payable to the Arizona Department of Water Resources. In addition to the hourly application fee, the applicant must pay any review-related costs associated with the application and the actual cost of mailing or publishing any legal notice of the application or any notice of a pre-decision administrative hearing on the application. Review-related costs are: (1) costs associated with a pre-decision hearing on the application, such as court reporter services and facility rentals for the hearing, and (2) mileage expenses for a site visit conducted before issuing a decision on the application. Failure to enclose the initial application fee will cause the application to be returned. Fees for a Designation of Assured Water Supply or a Modification of a Designation of Assured Water Supply Application are authorized by A.R.S. § 45-113 and A.A.C. R12-15-103. INITIAL APPLICATION FEE: $ 2000.00