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 __________________________________
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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
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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: ___________