HomeMy WebLinkAboutN-7-22 EHWS23-0130 071-080-024Public Health Department Danette York, MPH, Director
Dr. David Canton, DO, MPH, JD, Health Officer
Environmental Health Division
202 Mira Loma Drive T: 530.552.3880
Oroville, California 95965 F: 530.538.5339 buttecounty.net/publichealth
Executive Order (EO) N-7-22 Exemption Declaration Form
Executive Order (EO) N-7-22 does not apply to permits for wells that will provide less than two acre-feet per year of
groundwater for individual domestic users, or that will exclusively provide groundwater to public water supply systems as
defined in section 116275 of the Health and Safety Code. Please select which exemption applies and complete all applicable
sections below:
☐Well for Individual Domestic Use
As the owner of the proposed well or existing well to be altered and as a necessary condition on the issuance of a water well
construction permit for a new groundwater well or alteration of an existing groundwater well, I hereby declare for myself,
successors and assigns, that the well is a small diameter well (casing 8 inch diameter or less) and that no more than two (2)
acre feet per year will be pumped from the well AND that all water pumped from the well will be used only to supply water
for the domestic needs of an individual residence. Without limiting the foregoing, I acknowledge that such needs do not
include any commercial use regardless of scale, including, without limitation, use for the growing of food or other crops
for sale in any venue, including, without limitation, at a local farmer’s market.
Property Owner: _____________________________________________________________________________________
Signature of Property Owner: ________________________________________ Date: _____________________________
Address: ____________________________________________________________________________________________
AP Number: _________________________________________________________________________________________
Well Pump Capacity (GPM): ___________________________________________________________________________
Pump Installer: ______________________________________________________________________________________
Signature of Pump Installer: ___________________________________ Date: ___________________________________
☐Well for a Public Water Supply System
The public water system name is: ________________________________________________________________________
The public water system identification number is: ___________________________________________________________
As an authorized representative for the water system identified above, I hereby declare that the proposed well or existing
well to be altered will be exclusively used to provide groundwater to the public water supply system for human consumption
as defined in Health and Safety Code Section 116275. I further declare that a previously constructed public water supply
system well will not be replaced by the proposed well such that the previously constructed well can be used for purposes
other than human consumption.
Signature: _____________________________________ Date: ________________________________________________
Printed Name: _______________________________________________________________________________________
Address: ____________________________________________________________________________________________
AP Number: _________________________________________________________________________________________
☐Does Not Apply
Rich Wiley
0 Big Ridge Road, Berry Creek CA 95916071-080-024
Richard Wiley (Nov 30, 2023 13:46 PST)
Richard Wiley Nov 30, 2023
Executive Order N_7_22 Exemption Declaration
Final Audit Report 2023-11-30
Created:2023-11-27
By:Elias Medrano (bignsondrillingoffice@gmail.com)
Status:Signed
Transaction ID:CBJCHBCAABAAZQkfylSBWT8ju2SReZ-30nhK48CqGmnn
"Executive Order N_7_22 Exemption Declaration" History
Document created by Elias Medrano (bignsondrillingoffice@gmail.com)
2023-11-27 - 8:09:20 PM GMT
Document emailed to rwiley@skyleasing.com for signature
2023-11-27 - 8:10:07 PM GMT
Email viewed by rwiley@skyleasing.com
2023-11-30 - 9:42:35 PM GMT
Signer rwiley@skyleasing.com entered name at signing as Richard Wiley
2023-11-30 - 9:46:52 PM GMT
Document e-signed by Richard Wiley (rwiley@skyleasing.com)
Signature Date: 2023-11-30 - 9:46:54 PM GMT - Time Source: server
Agreement completed.
2023-11-30 - 9:46:54 PM GMT