<p> Application to Split A Permit and Request for Oregon Water Resources Department Issuance of Replacement 725 Summer Street NE, Suite A Salem, Oregon 97301-1266 Permits (503) 986-0900 www.wrd.state.or.us Affidavit of Non-Conveyance and Reading of Permit </p><p>State of Oregon ) ) ss County of )</p><p>I/We, , mailing address , telephone number ( ) , being first duly sworn depose and say:</p><p>1. Permit , has not been conveyed or withheld and remains appurtenant to my/our land.</p><p>2. I/We attest that I/we have read Permit .</p><p>______Signature of Affiant Date</p><p>______Signature of Affiant Date</p><p>Signed and sworn to (or affirmed) before me this _____ day of ______, 20____.</p><p>______Notary Public for Oregon</p><p>My Commission Expires: ______</p><p>Version 12/16/2014 Split a Permit Affidavit TACS</p>