Water Well Permit Application

WATER WELL PERMIT APPLICATION

 

Name of Owner ____________________________________________ Permit # ______

Address of Owner ________________________________________________________

Address and Location of Premises ________________________________City________

Name Well Drilling firm & size of well _______________________________________

Names of owners of residence at time of septic system installation __________________

Location of Sanitary Sewer and/or Septic System (existing and abandoned) ___________

________________________________________________________________________

Location of existing or abandoned water wells __________________________________

--------------------------------------------------------------------------------------------------

I hereby certify that facilities at the above location will be installed in compliance with Indiana State Board of Health Bulletin PWS 2 and Whitley County Ordinance #0- 97-08 as outlined in this application. I further certify that to the best of my knowledge all information contained in this application is correct. [To be filled out at issuance of permit]

Signature ___________________________________________ Date ________________

50'/100' to septic system, 10'/20' to sanitary sewer, 25'/50' fuel storage

10' from all structures ____ 25' from all water sources ____ 5' from property lines

________________________________________________________________________

A permit inspection fee of $10.00 Must be paid at the issuance of the permit. Checks or money orders must be made payable to the Whitley County Health Department.

 

 

THIS PERMIT EXPIRES ONE YEAR FROM DATE OF ISSUE

Signature ___________________________________________ Date ________________

Office Use Only:

Parcel #: ______________, Permit # for year: _______, Check #: _________, Receipt #: _________

Phone #: ____________________________, Section: ______, Twp: _______, Range: ___________