Agent Authorization Form

If you are filling out the Well Registration Form and you are NOT the current landowner of the property must fill out and submit this Authorized Agent Form provided below.

Download: Agent Authorization Form

Instructions:

Download and fill out the form
Have it signed by a Notary Public
Mail, hand deliver OR scan and upload completed form using the form below.

Property/Well Owner (required)

Address (required)

Phone (required)

Email (required)

Agent Name (required)

Address (required)

Phone (required)

Email (required)

I make, constitute, and appoint the above-named agent as my true and lawful agent (Agent) in my name, place and stead to comply with the Rules of the Blanco Pedernales Groundwater Conservation District (District) on the following described real property (Property) (required)

My Agent is authorized to

Submit Well Registration forms, and/or Apply for Operating Permits (required)

Yes

Receive Well Drilling Authorization (required)

Yes

File any and all reports required under District Rules (required)

Yes

If such Authorizations and/or permits are approved by the District, the Agent is authorized to employ the services of a Texas licensed water well driller and other qualified service providers to drill, equip, and operate Water Wells on the Property in accordance with the Rules of the District.

I hereby agree to indemnify and hold harmless the District or any person or other entity who relies on this Agent Authorization from any and all claims which may be asserted by me, my legal representatives, or any third party.

All rights, powers and authority of my Agent to exercise any powers granted hereunder shall be effective immediately upon the execution hereof. Such rights, powers, and authority of the Agent shall remain in full force and effect thereafter until such authority is terminated by me by written notice delivered to the District.

By (required)

Date (required)

Printed Name (required)

State of

County of

This instrument was acknowledged before me on this ______ day of __________

20_____________ by ________

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