EXHIBIT 2-H
Third Draft – 3/30/05
PRE-APPLICATION REQUEST
FORM
FOR WATER DISTRIBUTION
SYSTEM PERMITS
The information submitted on this form will be
reviewed by the District for three general purposes: (1) to determine the
type/level of permit needed, (2) to notify the applicant of any reports, well
testing and site-specific information needed to process a formal application;
and, (3) to conduct a “parcel query” within the District’s database to identify
and map the location of nearby wells, streams and/or habitats that may be
impacted by the proposed system.
The Application Requirement Checklist (last page
of this form) will be completed by the District, and will be provided to, and
discussed with, the applicant prior to the submittal of a formal application. This Pre-Application process is intended only
to provide general guidance to the
applicant based on the preliminary
information requested below. The guidance provided is not intended to be
exhaustive and additional information may be required when the formal
application is submitted and/or during the review and approval of the permit.
Pre-Application
Name and Date Received: SMITH
mm/dd/yy
Pre-Application and Parcel Query Fee: $140 for up to 2 hours staff time
Payment
Received: _________________________
APPLICANT AND PARCEL INFORMATION
1. Assessor’s
Parcel Number(s) for System _________________________________________________
2.
System
Site Address and Area _______________________________________________________
3. Name
of Applicant _________________________________________________________________
4. Mailing
Address ___________________________________________________________________
5. Contact
Numbers (ph/fax/e-mail) ______________________________________________________
6. Agent
Name/Contact Information ____________________________________________________
_______________________________________________________________________________
7.
Attach Map (8 ½ x 11 or larger): This Pre-Application
Form must include a copy of a basic parcel map of the area that shows the
parcels to be served and the approximate location of the wells(s) and/or water
supply facilities.
8. Attachments (please list attachments,
if any, included with this Pre-Application Form)
___________________________________________________________________________________
9. _____________________________________________________ ___________________
Signature
of Applicant or Agent (Please sign and
print name) Date
BASIC WATER SYSTEM INFORMATION
10. Please
complete the table below by briefly describing both existing and proposed:
water sources, land uses, and water demands on all parcels to be served by
proposed water system:
|
System Information |
Existing (briefly describe) |
Proposed (briefly describe) |
|
|
A. Water Source (groundwater, surface water, reclaimed,
desalination, etc.) |
|
|
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|
B.
Cal-Am water service |
|
|
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C.
Total number of wells |
|
|
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D.
Total number of parcels served |
|
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E.
Total acreage served (all parcels) |
acres |
acres |
|
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F.
Total number of structures served |
|
|
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|
G. Residential (potable, drinking water) |
|
|
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H. Commercial (potable, drinking water) |
|
|
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I.
Irrigation/agriculture (non-potable) |
acres |
acres |
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J.
Landscaping (non-potable) |
acres |
acres |
|
|
K. Other/live-stock (non-potable) |
|
|
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|
L.
Estimated water use, if known |
acre-feet per year |
acre-feet per year |
|
|
M. Water system infrastructure (tanks, treatment, backflow, meters, etc.) |
|
|
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Other relevant information, comments or
expansion on answers above: |
|||
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11. Land
Use/CEQA Information
□
Zoning
and land-use designations for parcels served (available from
________________________________________________________________________
□
Permits
and approvals required or received from other agencies (e.g., Planning
Department,
Building
Department, Health Department, Coastal Commission, CPUC). Make sure to list any recent or pending
subdivisions to be served by the proposed water system, and include file
numbers and resolution numbers used by the agencies.
______________________________
________________________________________________________________________
12. District Permits
Describe and list previous MPWMD
permits received, if any, including permit number and date issued. Include existing well meter information, if
applicable. ______________________________
______________________________________________________________________________
PARCEL
QUERY REFERRAL WORKSHEET
(District
Use Only)
Referral
Information
Pre-Application Name/Date: ________________________________________________________
APN: ________________________________________________________
Site Address/Area: ________________________________________________________
System Summary: ________________________________________________________
Referred To: ________________________________________________________
Date Referred: _____________________ Response requested by: __________
Referral Comments: ________________________________________________________
Additional Information
Requested
□
Well
log data for adjacent wells within ____ feet
□
Well
meter data for last ____ years
□
Site
history of previous wells and/or water use
□
Other
_______________________________________________________________________
RESPONSE SECTION
Standard Response Items
1.
Is
system wholly with District boundaries? □
YES □ NO ____________
2.
Is
system within “main” Cal-Am service area? □
YES □ NO ____________
3.
Is
well less than 1000 feet from existing wells? □
YES □ NO ____________
4.
Is
well less than 1000 feet from any of the five listed tributaries? □ YES □ NO ____________
5.
Is
well less than 1000 feet from dependent habitat and/or species?* □ YES □ NO ____________
6.
Is
well less than 1000 feet from the CVAA? □
YES □ NO ____________
7.
Is
well within the CVAA? CVAA Subunit # ______ □ YES
□ NO ____________
8.
Is
existing well registered with District? □
N/A □ YES □ NO ____________
9.
Is
existing well properly metered? □
N/A □ YES □ NO ____________
10. Is metered information
being submitted as required? □ N/A □
YES □ NO ____________
11. Other ???
12. Comments on standard response
items: _________________________________________________
_________________________________________________________________________________
Attachments
□
Parcel
map with project well(s), 500-foot and 1000-foot radii, adjacent wells and
parcel numbers
□
Aerial
photograph of parcel
□
Recent
water meter data for years __________________________________________________
□
______________________________________________________________________________
□
______________________________________________________________________________
Comments
and Additional Information
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
* Refer to Rule 22-B-6
Third Draft – 03/30/05
PRE-APPLICATION
TRACKING WORKSHEET
(District
Use Only)
Identifying
Information
Pre-Application Name/Date: ______________________________ APN: _________________
Site Address/Area: ________________________________________________________
System Summary: ________________________________________________________
Handouts
and Forms Provided
□
Form: Application To Create/Amend New Water
Distribution System Form Date_______
□
Form: Application To Create
□
Form: Supplemental Questionnaire (for CEQA
“non-exempt” applications) Date_______
□
Form: Residential Water Release Form and Water
Permit Application Date_______
□
Form: Commercial Water Release Form and Water
Permit Application Date_______
□
Form: Water Use Factors for Land Use Reporting
Method Date_______
□
Form: Well Metering Registration Forms Date_______
□
Form: Other_________________________________________________
Date_______
□
Procedures
for Completing Well Source and Pumping Impact Assessments Date_______
□
List
of Qualified Professionals Date_______
□
Requirements
for Documentation of Water Rights in CVAA Date_______
o
Copy
of Deed
o
CVAA
Riparian Rights (encourage completion prior to formal submittal)
o
Form:
IG-96-12, Declaration of Attorney Competency Date_______
o
Form:
Requirements of Format and Contents for Water Rights Documentation Date_______
□
List
of certified water testing laboratories
□
Referral
to local fire department
□
Other_________________________________________________
Date_______
CEQA
□
Does
the project fall under a categorical exemption?
□ Yes □ No □
N/A __________________
□
If
“no,” has CEQA been completed by another jurisdiction?
□
If
“no,” has the lead agency been determined?
□
If
CEQA has previously been completed, is updated and/or supplemental CEQA
analysis needed?
□
Does
an “overdraft” exist in the project area?
□
If
yes, is there adequate evidence to prove the project will not increase an
existing overdraft or that applicant has superior water rights?
□
Staff/Consultant
Notes
District Follow-up Needed: _______________________________________________________________
Conditions Needed:
_____________________________________________________________________
Comments:
___________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
APPLICATION
REQUIREMENT CHECKLIST
The District will complete the checklist below, provide a
copy and discuss the requirements with the applicant.
Identifying
Information
Pre-Application
Name/Date: __________________________ APN: ___________________
Site Address/Area: _________________________________________________________
System Summary: _________________________________________________________
Impact
Based Review Criteria
Land Use/Type: □ 1 parcel □ 2 parcel □ 3+ parcel □ Subdivision □ Commercial/industrial
Parcel Size (acres): □
≤1 □ 1-2.5
□ 2.5-10 □ 10-40 □ 40+
Demand (est. afy): □
≤1 □ 1-2.5
□ 2.5-10 □ 10+ □ Undetermined/Other ________________
Location: □
CV Uplands □ CVAA □
Parcel Query Data: □
No Receptors □ <1000’ from
wells □ <1000’ from tributary
____________ Other Criteria: □ Non-Potable Only □ Potable Use □ Within “main” Cal-Am service area
Misc/Site Specific: ________________________________________________________________
Required
Permit Review Level and CEQA Status
Exempt (No permit
required)__________________________________________________________
Permit Required: □
Level 1 (Waiver) □ Level 2
(Staff Permit) □ Level 3
(Hearing Officer)
□
Level 4 (Board of Directors)
________________________________________
CEQA- Categorical Exemption: □ No □ Yes
_____________________________________________
Requirements
for Acceptance of Formal Application
□
Form: Completed and signed Application Form (Form
Type/Number): _______________________
□
Payment
of $______________
□
Documentation
of Water Rights
o
Copy
of Deed
o
CVAA
Riparian Rights or other rights (option to complete prior to formal submittal)
□
Well
Source and Pumping Impact Assessments (including the following): (1)
o
Parcel
Query Information (from District)
o
Copy
of Well Driller’s Report
o
Copy
of Health Department Well Construction Permit
o
Results
of ___ hour pumping test [Dry season testing required: □ YES □ NO ________________]
□
Water
Quality Testing [□ Chapter 15 (1 connection); □ Chapter 22 (2+
connections)]
□
Form: Water Release Form and Water Permit
Application
□
Form: Water Use Factors for Land Use Reporting Method
□
Form:
Supplemental Questionnaire (for CEQA “non-exempt” applications)
□
Landscaping
Plans _______________________________________________________________
□
Water
System Meter Records/Well Pumping Records ____________________________________
□
Jurisdictional
Permit Information ____________________________________________________
□
CEQA
documentation _____________________________________________________________
□
Other/Special/Site-Specific
Requirements _______________________________________________
Review
Notes
Date(s) Discussed and Application Materials
Provided to Applicant:
________________________________
Tentative Formal Application Date:
________________________________________________________
District Follow-up Needed: _______________________________________________________________
Conditions Needed:
_____________________________________________________________________
Comments:
___________________________________________________________________________
_____________________________________________________________________________________
(1) The need for an
Assessment is waived if: non-potable and no receptors and not
within Cal-Am service area
SECOND DRAFT MARCH 30, 2005
PERMIT APPLICATION TO
CREATE NEW or AMEND EXISTING
WATER DISTRIBUTION
SYSTEM
|
Office Use Only |
|
Pre-Application
Name/Date ________________ Application
ID Number ________________ Date
Application Accepted ________________ Date
Application Deemed Complete ________________ |
FEE AMOUNT- The application fee must be paid concurrently with permit
application. The fee amount varies depending upon the level
of review required:
□
Level
2 Permit Fee: $1,400 for up to 20 hours of staff time
□
Level
3 or Level 4 Permit Fee: $2,450 for
up to 35 hours staff time
FEE RULES- For more complex projects where staff
time exceeds the number of pre-paid hours of staff time, a fee of $70 per hour
will be charged. See Rule 60 for complete fee information.
CONFIRMATION
OF PERMIT REVIEW LEVEL- The permit review
level required for this application is based upon a preliminary evaluation of
basic information provided in the Pre-Application Form. During the review of this application, staff
will confirm the appropriate review level.
If it is determined that a higher or lower level of review is required,
the applicant will be notified, and the higher or lower fee will be required or
refunded.
SECTION 1 -- APPLICANT INFORMATION
1. Name
of System ___________________________________________________________________
2. Assessor’s
Parcel Number(s) in System
______________________________________________
4. Name
of Applicant _________________________________________________________________
(If the applicant is not
the system owner or operator, the form must also be signed by the system
owner or operator.)
5. Mailing
Address ___________________________________________________________________
6. Contact
Numbers (ph/fax/e-mail) ______________________________________________________
7. Agent
(if any) ___________________________________________________________________
8. Agent
Mailing Address ___________________________________________________________
9. Agent
Contact Numbers (ph/fax/e-mail)______________________________________________