1. The Surface Water Licence Report form below is being used by Manjimup and Pemberton Landowners during April and May 2007, please submit a report for your water licence.
  2. Licence information – the information for licensee, water resource, entitlement, location, and authorised activities is as detailed in the relevant Licence to Take Water to which the report relates.
  3. Timing of estimates and date for return of report  – estimate of volume would be made before the relevant dam (or dams) began to be replenished by winter flows and reports would be sent to the Department of Water no later than 30 June each year. If a dam didn’t fill by the end of winter, two reports may be submitted, in November as a base level, and then the following June.
  4. Estimated volume and method of estimate – estimates of volume of the relevant dam (or dams) for the licence would be made either from the contour from a surveyed dam or by the method used in the Application for a 5C Licence to Take Surface Water. The Department of Water holds copies of surveys of dams where surveys have been conducted for licences.
  5. Combined use, evaporation and seepage volume  – the difference between the estimated volume of the dam and the licenced volume represents the combined volume of water extracted for use and discharged by evaporation and seepage.


Submitted to: Director General, Department of Water, PO Box K822, Perth WA 6842

Surface Water Licence Number:  


Description of Water Resource:

Annual Water Entitlement (kilolitres):

Location of Water Source:

Authorised Activities:

Taking of water for -

Location of activity -

Estimate of Dam Volume and Report of Use, Evaporation and Seepage:

Date - 

Estimated volume (kilolitres) - 

Report of use, evaporation and seepage volume (kilolitres) - 

Method of estimate* - surveyed dam (   )  licence application (   ) 

* indicate by X of estimate based on either contour from surveyed dam OR by method used in details of works in Application for Licence to Take Surface Water



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