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ANAHEIM PUBLIC UTILITIES WELL/BORING PERMIT THIS PERMIT IS NOT VALID FOR DRILLING IN CITY RIGHT-OF-WAY UNLESS ACCOMPANIED BY A RIGHT-OF-WAY CONSTRUCTION PERMIT PERMIT TYPE: BORINGS WELL INSTALLATION / REHABILITATION WELL DESTRUCTION PERMIT # ADDRESS OR CROSS STREET OF WELL LOCATION: ( ATTACH SITE PLAN) WELL OWNER NAME (INDIVIDUAL NAME) SITE/PROJECT NAME: COMPANY: (IF APPLICABLE) APPLICANT NAME: ADDRESS: COMPANY: CITY: STATE/ZIP ADDRESS: CITY: STATE/ZIP PHONE: EMAIL: PHONE: EMAIL: NOTIFY WATER INSPECTOR AT LEAST 48 HOURS PRIOR TO START AT (714) 765-4591 APPLICANT MUST SUBMIT A COPY OF THE WELL COMPLETION REPORT TO THE ANAHEIM PUBLIC UTILITIES AT THE ADDRESS LISTED ABOVE WITHIN 60 DAYS OF COMPLETION OF WORK OR EMAIL TO [EMAIL REDACTED] INJECTION WELLS ARE REQUIRED TO BE REGISTERED WITH USEPA AT HTTP://WWW.EPA.GOV/REGION9/WATER/GROUNDWATER/INJECTION-WELLS- REGISTER.HTML FAX OR EMAIL A COPY OF COMPLETED REGISTRATION FORM TO ANAHEIM PUBLIC UTILITIES AT (714) 765-4135 OR EMAIL TO [EMAIL REDACTED] I HEREBY AGREE TO COMPLY WITH ALL ORDINANCES, RULES AND REGULATIONS OF THE CITY OF ANAHEIM AND THE STATE OF CALIFORNIA PERTAINING TO WELL CONSTRUCTION AND DESTRUCTION. I ATTEST THAT I AM AUTHORIZED TO SIGN ON BEHALF OF THE PROPERTY OWNER AND/OR WELL OWNER. AGREE SIGNATURE PLEASE DESCRIBE WELLS/BORINGS BELOW: (ATTACH ADDITIONAL SHEETS, IF NECESSARY) (USE THE FOLLOWING ACRONYM FOR WELL TYPE: B = BORING; PW = PRODUCTION WELL; MW = MONITORING WELL; DW = DEWATERING WELL IJ = INJECTION WELL; VE = VAPOR EXTRACTION; VP = VAPOR PROBE) WELL ID TYPE DIAM (IN.) DEPTH (FT.) SCREEN INTERVALS EST. DATE OF DESTRUCTION ADMINISTRATIVE USE ONLY: WELL FEE = $128.75 APPLICATION FEE + $80 X (NO. OF WELLS) TOTAL FEE DUE: PAYMENT RECEIVED AND PERMIT AUTHORIZED BY: DATE ADMINISTRATIVE USE ONLY: WELL INSPECTED BY: INSPECTOR NAME DATE WELL COMPLETION REPORT RECEIVED YES ESTIMATED START OF WORK: 201 S. Anaheim Blvd., Suite 601, Anaheim, CA 92805 [PHONE REDACTED], Fax: [PHONE REDACTED]