Application For Permit To Construct, Modify Or Seal A Closed Loop Well System - Peoria City/county Health Department Page 2

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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

ATTACH A SHEET WITH DIAGRAM OF SYSTEM SITE SHOWING DIMENSIONS

Furnish a drawing indicating lot size, location of property lines, distances from proposed closed loop well system construction

to water wells, septic tanks, abandoned wells, property lines, seepage fields, sewers, and all other sources of contamination,

if they are within 200 feet of any closed loop well.

VARIANCE: In accordance with Section 920. Table C of the Water Well Construction Code, attach a sheet to identify the site

specific conditions for reducing the 50 feet separation distance, if the sewer pipe material is unknown.

REGISTERED CLOSED LOOP WELL CONTRACTOR INFORMATION:

Contractor Name __________________________________

Registration # __________________ Exp. __________

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.

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Signature of Registered Contractor

Date

One copy is retained by the Peoria City/County Health Department (where the permit is issued).

One copy is issued to the registered contractor.

FOR OFFICIAL USE ONLY

Permit # _________________________________

Date Issued: _____________

Expiration Date: _____________

Application Approval: _______________________________________________

Date: __________________

Construction Approval: ______________________________________________

Date: __________________

Final Approval: _____________________________________________________

Date: __________________

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.

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