Application for Over-Conversion Credit

Harris-Galveston Subsidence District
1660 W. Bay Area Boulevard
Friendswood, TX 77546-2640
Phone: (281) 486-1105 Fax: (281) 218-3700

Instructions: 

Submit one application form to the above address for each aggregate well system. The form must be received within ninety (90) days after the termination date of the permit(s) to be considered for a rebate.

A water meter must be installed and operating on both the groundwater and alternative water supplies for the entire withdrawal period in accordance with the Rules of the District and the Board's Area 3 Over-Conversion Credit Policy.
General:
Lead Well No:  
Well Owner:  
Mailing Address:
Address:  
City:    State:    Zip:     
Attention:
(If correspondence is being sent to a large organization, insert the specific person's name to whom you wish it directed.)
Phone Number:       Ext.:    

Over-Conversion Information:
Permit Term:   Begin:   End:  

Maximum authorized groundwater withdrawal (MG) as shown on permit:   
Actual groundwater withdrawal (MG)* during the permit term, not calendar year:
Actual alternative water use (MG)* during the permit term, not calendar year:
*Staff may request additional supporting documentation or details.
Request:

I request, on behalf of the above owner, that over-conversion credits be issued pursuant to the Rules of the Harris-Galveston Subsidence Districtand the Board's Area 3 Over-Conversion Credit Policy

I CERTIFY THAT A WATER METER WAS INSTALLED AND OPERATING ON BOTH THE GROUNDWATER AND ALTERNATIVE WATER SUPPLIES FOR THE FULL PERMIT TERM.

I CERTIFY THAT THE STATEMENTS MADE IN THIS APPLICATION AND STATEMENTS MADE IN ANY ATTACHED SUPPORTING DOCUMENTS ARE TRUE AND CORRECT.

Applicant/Agent Name:   
Please enter your e-mail address:    
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