Job Status / Completion Form Hea - Well-Pump-Distribution
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Ohio Department of Health
JOB STATUS / COMPLETION FORM
Well-Pump-Distribution
PERMIT INFORMATION (
must be completed when submitting for the Job Status or the Completion Form portions)
Private water systems contractor
Registration number
Phone #
Address of property
County
Permit #
JOB STATUS
The job status portion is used to document the stages of completion for the private water system. The job status form must be completed and submitted
in person, by fax, or by email to the local health district within ten (10) business days of completion of the portion of work completed by the private water
systems contractor noted above. This job status form is required according to Ohio Administrative Code Rule 3701-28-03 (O) effective April 1, 2011.
Date you completed this portion of the work
Is this installation for:
New Construction
Alteration
Briefly list all work completed - (Examples: “drilled well”; “set pump”, “installed pressure tank”, “installed UV disinfection system”)
COMPLETION FORM -
Record all information of work completed
The completion form portion documents the specific materials, placement, and installation methods used to complete the work. This form must be
completed and returned to the local health district prior to final approval of the private water system. This completion form is required according to Ohio
Revised Code 3701.34, 3701.44 and Ohio Administrative Code 3701-28-03(P), and must be submitted within thirty (30) days of completion of work.
Pitless Adapter or Unit
Pitless Adapter
Pitless Unit
Manufacturer
Style
Clear-way
Pull-through
Other (specify):
Method of cutting hole in casing
Depth below grade
ft. / in.
Method of attachment to casing
Pitless Attached to
Original Casing
Casing Extension
Casing Extension (if applicable)
Type of Original (Existing) Well Casing
Casing Type used for Extension (if applicable)
Final casing height above finished grade
inches
PVC
Steel
Thickness ________ in.
PVC
Steel
Thickness ________ in.
Method of attaching casing extension
Make and model of coupling device (if applicable)
Pump
Type
Depth of pum
p setting or intake
ft.
Submersible
Jet
Hand Pump
Other (specify):
Water pipe/line
Material used outside foundation
ASTM Standard
Material used inside foundation
ASTM Standard
Service Connections, Backflow Protection Devices and Yard Hydrants
No. of Service Connections
Backflow Protection Devices installed
Yard hydrants Installed
ASSE
1013
1015
1024
Frost-free
Sanitary (meets ASSE 1057)
Pressure Tanks
Location of Pressure Tank
NSF 61 Approved
Pressure Relief Valve Installed
Location of Sample Port
Yes
No
Yes
No
Continuous Disinfection
(UV, Chlorine, Iodine, Ozone Systems must meet the requirements in OAC 3701-28-15)
Installed
Yes
No
If “Yes”, complete the Continuous Disinfection Job Status / Completion Form.
HEA 5239 (Rev 03/2011)
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