WELL PERMIT APPLICATION

Transcription

1 Application #: WWA- PROPERTY OWNER INFORMATION Applicant Name Contact Name Mailing Address WELL PERMIT APPLICATION Permit #: WELL Street City/State Zip Code LICENSED CONTRACTOR DECLARATION Licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, as a well drilling contractor and such license is in full force and effect. Business Name Address Mailing Address License # Office Cell WELL INFORMATION Well Location APN - - Address/Cross Streets City Township Range Section Parcel Size Acre(s) Project Start Valley Foothills/Mountains Groundwater Basin: Kaweah Kings Tulare Lake Tule GPS Data (Use Decimal Degrees Where Applicable) TYPE OF WORK Latitude Longitude Elevation (ft.) Drilling Deepen Destruction Recondition Is this a Replacement Well? Yes No If Yes, then a Well Destruction Permit Application is Required. DRILLING METHOD (Construction Only) Cable Tool Rotary Reverse Rotary Air Rotary Other WELL TYPE (All Permits) Domestic (1 4 Connections) Dairy Supply Test Well Community (5+ Connections) Industrial Cathodic Protection Agricultural Soil Boring(s) Monitoring Well Other

2 WELL CONSTRUCTION Casing Material: PVC Steel Diameter in. Proposed Depth ft. Slot Size in. Gauge Perforation Depths to ft. Conductor Casing Yes No Diameter in. Depth ft. Seal Depth ft. (Minimum of 50 ft. Tremie pipe required for all well seals.) Seal Material: Neat Cement Sand Slurry Bentonite Other WELL DESTRUCTION Casing Material: PVC Steel Casing Diameter in. Well Depth ft. Depth to Water ft. Excavation Depth ft. Seal Depth ft. Seal Material: Neat Cement Sand Slurry Bentonite Other WELL SETBACKS (Construction Only) Setbacks from surrounding properties must be taken into consideration when selecting a well site location. Setback requirements may be increased by Tulare County if dangers of pollution, contamination or other adverse conditions are known to be present. If the well site is within a one mile radius of a landfill, there may be additional requirements. Measuring in feet, list distances from proposed well drilling location. Minimum requirements in parentheses. Front Property Line (25 ft.) Side Property Lines (5 ft.) Septic Tank & Leach Field (100 ft.) Sewer Laterals (50 ft.) Surface Water (25 ft.) Transmission Lines Storm Drain (50 ft.) Seepage Pit (150 ft.) Animal/Fowl Enclosure (100 ft.) Existing Active Well(s) (50 ft.) Underground Storage Tank (150 ft.) I certify that I have read this application and declare under penalty of perjury that the information contained herein is true, correct and complete. I hereby agree to comply with all State and Tulare County regulations pertaining to well construction, deepening and destruction. Within 30 days of work completed, I will furnish Tulare County Environmental Health Services Division a completed well completion report for well drilling, deepening and destruction. CONTRACTOR Print Name APPLICANT Print Name ENVIRONMENTAL HEALTH SERVICES DIVISION USE ONLY Received Fee Amount Receipt # Invoice # Payment Type: Cash Check # CC Approval # Received by: Flood Zone Landfill Other GIS Review PALMS CSLB Check C-57 Expiration :

3 SITE MAP The space below can be used to include a map. All maps must include: Major cross-streets associated with the parcel Setbacks documented above Structures on the parcel A directional arrow pointing North For new wells, that are not replacement wells, include the following on the map: Surface water (ponds, lakes and streams) within 300 ft. Canals, ditches, pipelines, utility corridors and roads within 2 mi. (Only for wells drilled below Corcoran Clay)

4 TO BE COMPLETED BY APPLICANT (For Construction of Domestic, Community, Agricultural, Dairy or Industrial Wells) Property Owner/Contact Person Name 1. What type of well is being drilled? Domestic Community Agricultural Dairy Industrial Serves 1 to 4 Service Connections/Homes. Serves 5 or more Service Connections/Homes 2. How many homes will the new well serve? Exclusively used to supply water for irrigation or other agricultural purposes. Exclusively used by a Dairy Farm for the milk production process. Exclusively used by a Business for the processes related to producing goods or services. 3. How many employees will be served by this well? 4. How many wells are currently on this parcel? Domestic Community Agricultural Dairy Industrial 5. Are there any inactive or abandoned wells on this parcel? Yes No (An inactive well is not routinely used but capable of being made operational with minimal effort. An abandoned well is a well that has not been used for at least one (1) year, or is in such disrepair that it can no longer produce water.) 6. What is/are the depth(s) of the existing well(s)? ft. 7. Are there any animal or fowl enclosures on this, or any adjacent, parcel? Yes No If Yes, how far is the enclosure from the proposed well site? ft. (May require site visit to verify.) 8. What is the reason for drilling a new well? Current well went dry. Current well about to go dry. How long has the well been dry? Additional well due to lack of production from existing source(s). First well on parcel. Other 9. What is/are the plan(s) for the existing well(s) once the new well(s) is/are drilled? Keep the existing well(s) active. (Keep the pump(s) installed and connected to power.) Destroy the existing well(s) using a licensed C-57 well contractor. File an Inactivation Permit. (Requires an annual permit fee.) I don t know. (Please call Environmental Health at (559) for more details.) 10. Has the recent drought influenced your decision to drill a new well? Yes No I certify that I have read this application and declare under penalty of perjury that the information contained herein is true, correct and complete.

5 TO BE COMPLETED BY APPLICANT OR APPLICANT S AGENT (For construction of new Agricultural, Dairy or Industrial wells subject to Senate Bill 252) Is this a replacement well? Yes No If Yes, this questionnaire is not required. However, a well destruction permit application must be submitted. The well being replaced must be destroyed prior to, or concurrently with, construction of the new well. Pursuant to Section of the California Water Code, Tulare County Environmental Health is required to request the following information, to the extent that it can be reasonably known, from an applicant, or the applicant s agent, as part of an application for a well permit. Proposed Capacity: Acre-Feet Estimated Pumping Rate: gpm Anticipated Pumping Schedule: Estimated Annual Extraction Volume: Acre-Feet per Year Size of Service Area: Acres Seasonal Fluctuations: Water Table Depth: ft. Recharge Area: Recharge Rate: gpm Location to Flood Plain: Use the grid below to input information about existing wells on the parcel that will remain active, and attach any information of capacity or pumping tests completed for the existing wells. Well Use Depth (ft.) Diameter (in.) Screen Intervals Pump Rate (gpm) Well 1 Well 2 Well 3 Well 4 Well 5 Well 6 Estimated cumulative extraction volume of new well before January 1, 2020: Acre Feet