Application For Permit To Construct, Modify Or Abandon A Water Well - Peoria City/county Health Department Page 2
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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
ATTACH A SHEET WITH DIAGRAM OF SYSTEM SITE SHOWING DIMENSIONS
Furnish septic system plot or draw the proposed construction site with dimensions showing the water well, direction of slope,
distances to buildings and property lines, sewer lines, all septic system components including septic tanks and seepage fields,
and other sources of contamination, e.g., abandoned wells, storm water dry wells and underground storage tanks. Indicate
distance to community water supply, if available. If there is an existing well on the property, indicate location and status.
WORK SCHEDULE*:
*NOTE: Illinois Water Well Construction Code, Section 920.130 g) Notification. Any person who constructs or deepens
a water well for which a permit has been issued under this Part, shall notify the Department, or approved local health department, or approved unit
of local government by telephone or in writing at least two days prior to commencement of the work.
Estimated scheduled date to start work on water well (MM/DD/YR): _________
WATER WELL PUMP INFORMATION: o
Check if anticipated pumping capacity is greater than 100,000 gallons per day.
Pump Type: _________________________
Capacity: _________ gpm
Storage/Pump Cycle: _________ gallons
LICENSED WATER WELL CONTRACTOR INFORMATION:
Contractor Name __________________________________
License # ____________________________________
Mailing Address ___________________________________
Office Phone Number ___________________________
City ___________________
State ______ ZIP ________
Cell Phone Number ____________________________
E-mail ___________________________________________
FAX Number __________________________________
LICENSED WATER WELL PUMP INSTALLATION CONTRACTOR INFORMATION:
Contractor Name __________________________________
License # ____________________________________
Mailing Address ___________________________________
Office Phone Number ___________________________
City ___________________
State ______ ZIP ________
Cell Phone Number ____________________________
E-mail ___________________________________________
FAX Number __________________________________
REGISTERED CONTRACTOR CERTIFICATION:
I certify that the attached information is complete and correct and that the work will conform to the current
Illinois Water Well Construction Code and to the current Illinois Water Well Pump Installation Code.
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
––––––––––––––––––––
Signature of Licensed Water Well Contractor/Property Owner
Date
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
––––––––––––––––––––
Signature of Licensed Water Well Pump Installation Contractor/Property Owner
Date
COPIES:
THREE COPIES ARE RETURNED TO THE PEORIA CITY/COUNTY HEALTH DEPARTMENT WHERE
THE PERMIT IS ISSUED. One copy is retained by the Peoria City/County Health Department (where the permit is issued).
One copy of the approved application is sent to Illinois State Water Survey. One copy is sent to the water well contractor.
FOR OFFICIAL USE ONLY
o
o
Permit to:
Construct
Seal
Permit # _________________________________
Date Issued: _____________
Expiration Date: _____________
Application Approval: ___________
Construction Approval: ___________ Date: _______
Date: _______
Final Approval: _______________________________________________________
Date: __________________
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