Application For Permit To Construct, Modify Or Abandon A Water Well - Peoria City/county Health Department
Download a blank fillable Application For Permit To Construct, Modify Or Abandon A Water Well - Peoria City/county Health Department in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Application For Permit To Construct, Modify Or Abandon A Water Well - Peoria City/county Health Department with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2Peoria City/County Health Department • Environmental Health
2116 N. Sheridan Road • Peoria, IL 61604 • PH: 309/679-6161 • FAX: 309/679-6174
Email: •
APPLICATION FOR PERMIT TO CONSTRUCT, MODIFY OR ABANDON A WATER WELL
PERMIT FEE: $100.00
DO NOT SEND CASH
OWNER INFORMATION:
Name ___________________________________________
Phone Number ________________________________
Mailing Address ___________________________________
FAX Number __________________________________
City ___________________
State ______ ZIP ________
E-mail _______________________________________
WELL SITE INFORMATION:
Property Address __________________________________
Township Name _______________________________
City ________________________________ ZIP ________
County Property Identification # ___________________
County _______________________
Subdivision _____________________
Lot # _________________________
Township ___________
Range _________ Section _________
______ ¼ of the _______ ¼ of the ______ ¼
Directions to the site:
WATER WELL INFORMATION:
o
o
o
o
Permit to:
Construct
Deepen
Repair
Seal
o
o
o
o
Well Type:
Dug
Driven
Bored
Drilled
o
o
o
o
for a:
B. Semi-Private Well
C. Non-Community Well
A. Private Well
D. Non-Potable Well
Complete if “B” or “C” is selected: Number of people served ______ Type of facility _____________
(If “C” is checked, an Application for Permit to Construct, Alter or Extend a Non-Community Public Water Supply must be submitted)
o
o
o
o
o
use:
Residential
Commercial
Livestock
Irrigation
Other: _____________________
WELL CONSTRUCTION OR ABANDONMENT INFORMATION:
1. If well log is available, attach the log to this form. 2. If well log is not available, well must be sealed from bottom to top.
Borehole: Size _________(in/ft)
Depth ________(ft)
Size _________ (in/ft)
Depth _________ (ft)
o
o
o
o
Aquifer:
Sand and Gravel
Limestone
Sandstone
Other ____________________________
Casing: Type __________________
Size _________ (in/ft)
Estimated Amount ________(ft)
Liner: Type __________________
Size _________ (in/ft)
Estimated Amount ________(ft)
Top of Liner _____ (ft)
Type Seal___________
Bottom of Liner ______ (ft)
Type Seal ___________
o
o
o
o
o
o
Existing water well on property?
Yes
No
Will it be used?
Yes
No
Is it to code?
Yes
No
o
o
o
o
o
Existing well to be sealed:
Well in building
Well in pit
Pit retained
Pit eliminated by:
Contractor
Owner
o
o
Is well free of obstruction?
Yes
No
If No, at what depth is obstruction? _________ (ft)
IMPORTANT NOTICE:
The Illinois Department of Public Health is requesting disclosure of information necessary to accomplish
the statutory purpose as outlined under Public Act 85-0863. Disclosure of this information is mandatory.
Page 1 of 2
ADVERTISEMENT
0 votes
Related Articles
Related forms
Application For Permit To Construct, Modify Or Seal A Closed Loop Well System - Peoria City/county Health Department
Medical
Application For Permit To Construct A Private Sewage Disposal System Form - Adams County Health Department
Legal
Application For Permit To Operate Public Accommodations Form - Apache County Public Health Services District
Business
Related Categories
Parent category: Medical