NORTHERN TERRITORY OF AUSTRALIA
APPROVED FORM 11 (25/01/2011)
APPLICATION FOR GRANT OR RENEWAL OF LICENCE TO TAKE OR USE SURFACE WATER
Pursuant to section 45 of the Water Act
Application No ...... …………... (office use only)
1. GENERAL (Contact information will be made public via the licence register)
Previous licence number (if applicable): ......
Business Name and ABN (if applicable): ………………………………………….…………
Contact Name: ...... ……………......
(Surname) (Given Name)
Postal Address: ......
Phone No...... (Wk) Phone No …………………(Hm)
Phone No…………………….(Mobile) Fax No ………………………….
Email Address: ………………………………………………………………………..
2 (a) PROPERTY on which water will be used
Lot: ...... …....….……………………... / Section No: ...…...... ……………..Hundred of: ...... …...... ………….. / Portion No: …………...... ….……….
Township:...... ……………...………… / Lease No/name: ...... …………
I am the owner/occupier/lessee of the property (please circle).
Other: …………………………..
(b) Name of water course or water body from which water will be taken or used?
………………………………......
…………………………………………………………………………………………………...
(c) Will this be used for drinking/domestic purposes also? …………………………………
(d) Do you have legal access to this water way from your property? ……………………..
(If not you will be required to obtain written permission from the land owner)
(e) Please provide a map showing location of existing or proposed pump site, the location where the water is to be used, the method and route of conveying the water, and the lands in the immediate vicinity (i.e. lot, portion, section, lease numbers, boundaries etc) as an attachment to this application.
(f) PUMP/METER DETAILS
Pump
/Meter
Make / Model / Delivery Capacity (Litres/s) / Make / Model / Installation date3. INTENDED USE
a) AGRICULTURE – to provide irrigation water for primary production, including related research.
Area Under Irrigation (ha)Drip or Tape / Micro Spray / Overhead Spray / Centre Pivot and or
Lateral Move
Permanent Crop
……………………………………………………………………………………………………………………………………………………………… / ……………………………………… / …………………………………………......
...... / ………………………………………………………………… / ………………………………......
......
......
Annual Crop
……………………………………………………………………………………………………………………………………………………………… / ……………………………………… / ………………………………………
...... / ………………………………………...... / ……………………………...... ………………..……………………………
......
......
Maximum annual usage: ……………………………………… Megalitres (ML)
Please use the Maximum Monthly Water Usage Table at the end of this form to provide details on monthly water usage. You will also be required to submit a Property Development Plan with your application. Please contact the Department for an approved format.
b) AQUACULTURE – to provide water for commercial production of aquatic animals and related research.
Pond Volume (Megalitres) / Pond Area (Hectares) / Annual Megalitres Taken/Used / Maximum Megalitres/month Taken/UsedSaline Water
Fresh Water
Maximum annual usage: Saline ……………and Fresh …………….. Megalitres (ML)
Please use the Maximum Monthly Water Usage Table at the end of this form to provide details on monthly water usage. You will also be required to submit a Property Management Plan with your application. Please contact the Department for an approved format.
c) PUBLIC WATER SUPPLY – to provide source water for drinking purposes delivered through community water supply systems.
TOWN / Current population / Population in 5 years / Population in 10 years……………………. / ……………… / …………………. / ………………………….....
Maximum annual usage: ………………………………………….. Megalitres (ML)
Please provide and attach documentation regarding details in relation to intended use for public water supply. Please use the Maximum Monthly Water Usage Table at the end of this form to provide details on monthly water usage.
d) INDUSTRY – to provide water for industry, including secondary industry and mining or petroleum activity, and for tertiary industry uses such as irrigation of recreational or amenity areas;
Type of industry......
Maximum annual usage: ………………………………………….. Megalitres (ML)
Please use the Maximum Monthly Water Usage Table at the end of this form to provide details on monthly water usage. You will also be required to submit a Property Management Plan with your application. Please contact the Department for an approved format.
e) OTHER USE – Not Covered by 3(a) to 3(d)3
Details: ......
……………………………………………………………………………………………………….…
Maximum annual usage: ……………………………………….. Megalitres (ML)
Please use the Maximum Monthly Water Usage Table at the end of this form to provide details on monthly water usage. You will also be required to submit a Property Management Plan with your application. Please contact the Department for an approved format.
4. ADDITIONAL INFORMATION
(a) Will there be any waste water generated by the proposed use? If yes, state the type of waste generated, estimated quantity and proposed means of disposal :
………………………………………………………………………………………………….
…………………………………………………………………………………………………
…………………………………………………………………………………………………
(b) Additional information may be required regarding the effect of the proposed extraction on the surface water resource.
Additional comments/advice/information given in support of application:
…………………………………………………………………………………………………….
…………………………………………………………………………………………………….
…………………………………………………………………………………………………….
…………………………………………………………………………………………………….
5. APPLICATION FEE
A fee of $..…………...... must accompany this application.
Under section 71 (B) of the Water Act, the applicant is required to bear the costs of advertising a public notice of this application for grant of licence to take surface water. This advertisement will be as per the approved formatting and in the appropriate print media as determined by the Controller of Water Resources. Notice of this application will not be advertised until the required costs are met by the applicant. Under section 71(C) of the Water Act, the Controller of Water Resources should, if possible, make a decision regarding this application within 60 days of the notice being published.
6. DISCLAIMER OF PERSONAL INFORMATION
I agree that certain information pertaining to the licence may be publicly available via a register of water extraction licences.
¨ Please tick if you wish to withhold the disclosure of information on the register. Under section 95 of the Water Act, any licence holder can apply to have information withheld from the register. Please attach supporting documentation for any such request.
...... …………
Applicant's Signature
Date ……………………………………….
To (please mail to your regional branch):
Controller Water Resources Controller Water Resources Controller Water Resources
PO Box 496, Palmerton, NT 0831 PMB 123 Katherine 0852 PO Box 1120 Alice Springs, NT 0871
Ph: 89 993632 Fax: 89 994445 Ph: 89738840 Fax: 89 7388894 Ph: 89 519215 Fax: 89 519268
Maximum monthly water usage table
pRIMARY uSE
YEAR / JanML / Feb
ML / Mar
ML / April
ML / May
ML / June
ML / July
ML / Aug
ML / Sept
ML / Oct
ML / Nov
ML / Dec
ML
sECONDARY uSE
YEAR / JanML / Feb
ML / Mar
ML / April
ML / May
ML / June
ML / July
ML / Aug
ML / Sept
ML / Oct
ML / Nov
ML / Dec
ML
TERTIARY USE
YEAR / JanML / Feb
ML / Mar
ML / April
ML / May
ML / June
ML / July
ML / Aug
ML / Sept
ML / Oct
ML / Nov
ML / Dec
ML
Department of Lands Resource Management 7/12/2015, version 1
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