Application For Permit To Construct, Modify Or Seal A Closed Loop Well System - Peoria City/county Health Department

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Peoria 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 SEAL A CLOSED LOOP WELL SYSTEM
PERMIT FEE:
DO NOT SEND CASH
$ _______
($200 includes 10 bore holes; $10 per additional bore hole)
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:
SYSTEM INFORMATION:
Facility Type: ____________________________________
o
o
o
o
o
o
Permit to:
Construct
Modify
Seal
Bore Type:
Vertical
Directional
Both
o
o
Coolant:
USP Food Grade Propylene Glycol
Other (specify) ____________________________________
SYSTEM LOCATION:
GPS Coordinate W: ____________________
GPS Coordinate N: _____________________
CONSTRUCTION INFO:
Boreholes: Number _____
Depth (ft): ______
MODIFICATION INFO: New Boreholes: Number _____
o
o
Depth (ft): ______
Tracing wire/locators?
Yes
No
(If the original installation report is available, attach a copy of the report to this form)
SEALING INFO: Description of Sealing
(If the original installation report is available, attach a copy of the report to this form)
WORK SCHEDULE*:
*NOTE: Illinois Water Well Construction Code, Section 920.200 f) Notification. Any person who constructs,or deepens or modifies
a closed loop 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 (MM/DD/YR): ____________________
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