HomeMy WebLinkAbout066-360-055 EHWS24-0019 WELL PERMIT APPLICATION PACKETWATER WELL
CONSTRUCTION PERMIT
Small Diameter Domestic Well (casing 8 inch diameter or less)Large Diameter Well (> 8 inch diameter)
Public Water System Well Repair/Deepening (same pump capacity)Destruction Fire Suppression
Replacement, Same Pump Capacity, 100 ft of destroyed well Frost Protection
Update: May, 2022
Date paid: ______ $_______________
Receipt No. _________
APPLICATION
APN #: ______________________________ TRAKiT #: ______________________________
Applicant Name (Please print) Property Owner Name
Applicant Mailing Address Construction Site Address
City State Zip City State Zip
Applicant Phone Number Property Owner Phone Number
Drought related (dry well, subsidence)? Yes No
Subbasin: Wyandotte Butte Vina Outside of Subbsasin C-57 Well Driller Name
GSA: Proposed Depth: Casing Diameter:
The Important Information for Applicant/Property Owner (located on the back of this page) has been reviewed by applicant or, if the applicant
is not the property owner, the information has been shared with the property owner. Yes No
Additional Information for Large Diameter Wells Only
Within Water District? Yes No Engineered Pump Capacity: GPM
Name of Water District: Acreage of Parcel(s) to be Served:
If other wells also serve the above referenced parcel(s), provide an attachment that specifies for each well: (1) APN, (2) Pump
Horse Power, and (3) Pump Capacity in Gallons per Minute (GPM). Note: Maximum pump capacity is 50 GPM/acre served.
Applicant Acknowledgement
As the applicant, I am: the property owner, the C-57 licensed well driller, the property owner’s authorized representative.
I certify that the information in this application is correct to the best of my knowledge.
Applicant Signature Date of Application
PERMIT
CONSTRUCTION APPROVAL
This permit is issued based on review of the attached design and it has been determined that it meets the requirements of Butte County Code
Chapter 23B, Water Wells. In coordination with Butte County Department of Water and Resource Conservation and local Groundwater Sustainability
Agencies, the County determines that it is not likely that the proposed well will interfere with the production and functioning of existing nearby wells,
and further, that the proposed well is not likely to cause subsidence that would adversely impact or damage nearby infrastructure.
Environmental Health Specialist Date of Issuance
Comments/Conditions:
FINAL APPROVAL AND CERTIFICATE OF COMPLETION
Well Construction/Destruction Approval Well Final Approval/Certification of Completion
Environmental Health Specialist Date Environmental Health Specialist Date Completed by Environmental Health Completed by applicant Applicant: See important information on reverse side of application.
Update: May 11, 2022
A.Well Seal Inspection
1.Requested by:Call in date/time:
2.Ready date/time:A.M.P.M.
3.Inspection date:Approved No seal inspection
4.Inspector name:
5.Comment (if seal not approved or inspection not performed):
B.Water Well Report/Destruction Report
2.Date received:Date reviewed:
3.Reviewer name:
Approved Not received
4.Comment (if report not approved or not received):
C.Disinfection Report
2.Date received:Date reviewed:
3.Reviewer name:
Approved Not received
4.Comment (if report not approved or not received):
D.Well Final Inspection
2.Inspection date:Inspector:
Approved Not inspected by EH but Certification of Completion
provided by a licensed well driller or pump contractor?
3.Comment (if final not approved or Certificate of Completion not received:
4.For large diameter wells only, capacity of installed pump verified by:
Pump “specification sheet”Other; please explain:
!!! Important Information for Applicant/Property Owner !!!
➢Permit valid only for construction in the location shown on the attached plot plan, stamped “Approved.” Variation from
the approved location must have prior approval by Environmental Health.
➢Permit valid only if drilled by a C-57 Licensed Contractor.
➢Environmental Health recommends that the water from this well be tested for water quality when the well is completed in
order to confirm that the water is potable (safe drinking water quality).
➢Environmental Health will not release for occupancy any future building permit for a residence served by this well that
has not been tested, at a minimum, to verify the absence of total and fecal coliform and a nitrate level of less than 10
milligrams per liter.
➢Permit valid 1 year from the date of issuance.
Official Use Only Below
Update: June 6, 2022
Trakit