Well Construction, Modification, and Well Abandonment Application

To apply for well construction modification, or abandonment, please complete the following form in FULL, print, and mail to the LCHD with corresponding *fee. Please note there is NO fee for applications for well abandonment.

APPLICATION FOR PERMIT TO CONSTRUCT, MODIFY OR ABANDON A WATER WELL

Steps

  1. 1. 1
  2. 2. 2
  3. 3. 3
  4. 4. 4
  • 1

    1. Livingston County Health Department
    2. APPLICATION FOR PERMIT TO CONSTRUCT, MODIFY OR ABANDON A WATER WELL
    3. Fees:
    4. Check only if this applies:

       

    5. Property Information
    6. Water Well Information
    7. Permit To:
    8. For:
    9. Use:
    10. Complete if you selected Semi-Private or Non-Community Water Well
    11. If Non-Community Water Well is Selected a Non-Community Public Water Supply Must be Submitted.
    12. Capacity
    13. Well Construction or Abandonment Information
    14. Notes for Well Abandonment: If well log is available, attach the log to this form, If well log is not available, well must be sealed from the bottom to the top.
    15. Borehole:
    16. Aquifer:
    17. Casing:
    18. Liner
    19. Existing water well on property?
    20. Will it be used
    21. Is it to code?
    22. Existing well to be sealed?
    23. FOR OFFICIAL USE ONLY
    1. Environmental Health


      Mailing Address
      310 E Torrance Avenue
      Pontiac, IL 61764

      Phone: 815-842-5916
      Fax: 815-842-4070