BRAZORIA COUNTY GROUNDWATER CONSERVATION DISTRICT
Application for Annual Minimum Production Fee Pre-Payment
Name of Well Owner: _________________________________
Business Name: _________________________________
Well Information: Physical Address: ________________________________
City _____________________ Zip: ________ Well No. _________________
Mailing Address of Owner: _________________________________________
City _________________ State __________ Zip ______________
Annual Prepayment Fee: $30.00 □
Attached
Make Check Payable To: Brazoria County Groundwater Conservation District
_________________ Date: __________________ Start Meter Reading:
I understand that this annual pre-payment option is only applicable to permittees who can verify that the monthly production fees, per month, per each permitted well, are equal to or less than the minimum monthly production fee, per well, per month of $3.00 as established by the Board of Directors for the Brazoria County Groundwater Conservation
District. By my signature below, I hereby verify that I am in compliance with these requirements and further, I understand that at the end of the one-year pre-paid period, I will be required to complete and submit an Annual Production Report to the District. If at the end of this one-year period, the groundwater production amount exceeds the fore stated limit, I will be required to pay the difference in fees and that late penalties may apply.
Signature ___________________________ Printed Name:________________________
Title: ___________________________ Date: _________________________
Mail To:
Brazoria County Groundwater Conservation District
111 E. Locust Street
Building A-29, Suite 140
Angleton, Texas 77515