Water Pump Installation Report

2. 310 E. Torrance Ave, Pontiac, Illinois
   
4. INSTALLATION REPORT FOR WATER WELL PUMPS
6. Complete within 30 days and sent to Livingston County Health Department
8. Type of Installation:

   1. New Construction
   2. Existing Well (with or without pump)
9. Date of Installation
11. County
12. Permit Number (new construction only)
14. Owner's Name
16. Well Location (well Site Address)
17. City, State, Zip Code
19. Pump Manufacturer
20. Model
22. Well Depth (ft.)
23. Depth Pump Set (ft.)
24. Pumping Capacity (gpm)
26. Static Water Level (ft.) Below Top of Cashing
27. Pumping Level (ft.) Below Top of Casing
29. Pitless Adapter Manufacturer
30. Model
32. How Attached to Casing:

    1. Screw On
    2. Welded
    3. Compression
33. Type of Well Cap
35. Tank Working Cycle (gallons)
36. Captive Air:

    1. Yes
    2. No
37. Pump Equipment Disinfected:

    1. Yes
    2. No
39. Pump Installation Contractor
40. License Number
42. Comments:
Leave This Blank:


44. 1. Receive an email copy of this form.
45. Email address

    This field is not part of the form submission.

46. Submit Submit and Print

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