Clearlake, CA · Lake County
Domestic Well Only Application Package
Property owners and well drillers use this package to apply for a domestic-use well permit and provide required well and site information.
What this form is
The package includes a domestic well permit application, a supplemental declaration for individual domestic use, and a well clearance form for the property owner. It asks for property, owner, and well driller details, proposed well construction information, and signatures. The instructions require an original application with the well driller’s wet signature and a map; the permit application states that it is valid for one year from issuance.
Who needs it
Property owners and licensed well drillers applying for a domestic-use well permit in Lake County need this package.
How to submit it
Submit the original application with the well driller’s wet signature; faxed and emailed applications will not be accepted. The document lists Lake County Environmental Health Division at 922 Bevins Court, Lakeport, CA 95453.
About notarization
The application has no notary block; the signer signs and dates it, and the supplemental declaration is made under penalty of perjury.
How to submit this form
- 1
Download The Package
Download the Domestic Well Only Application Package PDF.
- 2
Complete The Application
Enter the property and well driller details, proposed work, and well construction information.
- 3
Gather Required Attachments
Complete all attachments and include a map. The property owner completes the well clearance form.
- 4
Submit The Original
Submit the original application with the well driller’s wet signature to Lake County Environmental Health Division; do not fax or email it.
Frequently asked questions
- Do I need a notary for the Domestic Well Only Application Package?
- No. The package has no notary block; the signer signs and dates it, and the supplemental declaration is made under penalty of perjury.
- How do I submit the domestic well application?
- Submit the original application with the well driller’s wet signature to Lake County Environmental Health Division at the address listed in the package. Faxed and emailed applications are not accepted.
- What should I include with the well permit application?
- Include a map, either the one provided or your own, and complete all attachments. The well clearance form must be completed by the owner for domestic well permits.
Need something notarized?
This Domestic Well Only Application Package doesn’t need a notary — but if you have another Clearlake form that does, a commissioned online notary can help.