APPENDIX "D"
AFFIDAVIT ON USE OF
BESSEMER DITCH SHARES ST. CHARLES MESA WATER DISTRICT PARCEL NO. ____________

NAME:______________________________________________________

TELEPHONE NUMBER:__________________________________________

I am the owner or former owner of the property described as St. Charles Mesa Water District Parcel No. (See above) ("Property"). (Circle appropriate description.)

To my knowledge, the prior owners/irrigators of the Property were:_____________________________________

Other water rights/well used to supplement the Bessemer Ditch irrigation supply for the Property include: (if possible, include well permit numbers, well capacities and quantities of water available, acre feet/year available from other surface diversions.):_________________________

The method of irrigation used on the property was (for example, flood, sprinkler, etc.):____________________________________
This property is now used for (check one):

Growing Crops:__________________________
Commercial:_____________________________
Other (Explain):________________________

The history and details of my irrigation of this property are set forth below:

Year(s)

# of Acres Irrigated By Bessemer Ditch Shares

# of Shares UsedWas the supplemental source of irrigation supply used?

Crops grown* insert number from choices below

If more than one crop, acreages for each crop

Irrigation Season (approx dates of first and last irrigation) 

Other relevant information concerning the historical use of the Bessemer Ditch shares on the property:

______________________________________________________________________________

I,_________________________________, state that the preceding information is accurate to the best of my knowledge.

Date:________________________, 20____________________Signature:_________________

* Crops grown, choose from:

1. Alfalfa
2. Beans
3. Corn
4. Pasture Grass
5. Small Grains
6. Sorghum
7. Soybeans
8. Tomatoes
9. Other Vegetables (truck crops)