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APPLICATION FOR PERMIT TO CONSTRUCT, MODIFY OR ABANDON A WATER WELL
Fees:
1. Permit Fee-$100.00
2. Water Sample Fee-$50.00
3. TOTAL PERMIT FEE-$150.00
4. Abandon Water Well Fee-Free
Check only if this applies:
1. If this box is checked, the permitting authority plans to complete a comprehensive inspection and shall be notified of any scheduling changes
Property Information
Owner:
Phone Number
Mailing Address:
City, State, Zip Code
Phone Number
Property Address:
City, State, Zip Code
County Name:
Township:
County Property Identification Number:
Subdivision:
Lot Number:
Township Number
Range
Section
1/4 of the
1/4 of the
1/4
Directions to Site
Water Well Information
Permit To:
1. Construct
2. Deepen
3. Repair or
4. Seal a (please select what type of well below)
5. Dug
6. Driven
7. Bored
8. Drilled
For:
1. A Private Water Well
2. Semi-Private Well
3. Non-Community Well
Use:
1. Residential
2. Commercial
3. Livestock
4. Irrigation
5. Other
Complete if you selected Semi-Private or Non-Community Water Well
Number of People Served
Type of Facility
If Non-Community Water Well is Selected a Non-Community Public Water Supply Must be Submitted.
Capacity
1. Check if anticipated pumping capacity is greater than 100,000 gallons per day
Well Construction or Abandonment Information
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.
Borehole:
Size in/ft.
depth ft.
Size in/ft.
depth ft.
Aquifer:
1. Sand and Gravel
2. Limestone
3. Sandstone
4. Other
Casing:
Type
Size in/ft.
Estimated Amount ft.
Liner
Type
Size in/ft.
Estimated Amount ft.
Top of Liner ft.
Type Seal
Bottom of Liner ft.
Type Seal
Existing water well on property?
1. Yes
2. No
Will it be used
1. Yes
2. No
Is it to code?
1. Yes
2. No
Existing well to be sealed?
1. Yes
2. No
By whom?
FOR OFFICIAL USE ONLY
Approved by
Date
Construction Permit Number FIPS/Number/Year
Sealing Permit Number FIPS/Number/Year
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ATTACH A SHEET WITH DIAGRAM OF WELL SITE SHOWING DIMENSIONS Furnish septic system plot or draw the proposed construction site with dimensions showing the water well, direction of slope, distances to buildings and property lines, sewer lines, all septic system components including septic tanks and seepage fields, and other sources of contamination, e.g. abandoned wells, storm water drywells and underground storage tanks. Indicate distance to community water supply, if available. If there is an existing well on the property, indicate location and status.
WATER WELL PUMP INFORMATION
Pump Type
Capacity (gpm)
Storage/pump cycle (gallons)
WORK SCHEDULE
Estimated Scheduled Date to start work on water well:
*Note: Illinois Water Well Construction Code, Section 920.130 g) Notification. Any person who constructs or deepens a water well for which a permit has been issued under this Part, shall notify the Department, or approved local health department, or approved unit of local government by telephone or in writing at least two days prior to commencement of the work.
LICENSED 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 and to the current Illinois Water Well Pump installation Code.
Licensed Water Well Contractor
Contractor's Name
License Number
Address
City, State, Zip Code
Office Phone
Fax Number
Cell Phone
E-mail Address
Signature Licensed Water Well Contractor/Property Owner
Date
Licensed Water Well Pump Installation Contractor
Pumping Contractor's Name
License Number
Address
City, State, Zip Code
Office Phone
Fax Number
Cell Phone
E-mail Address
Signature Licensed Water Well Pump Installation Contractor
Date
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Indicate location of and distances from the proposed well location.
Please submit a drawing below indicating the location and distance of each item.
Water Well Application Plot Plan (pdf)
https://il-lchd.civicplus.com/DocumentCenter/Index/36
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INSTRUCTIONS
CHECK THE FOLLOWING BEFOR MAILING:
Driller-
Permit application is mailed to local health department. Refer to the listing of counties provided to you by the Illinois Department of Public Health. If a county is not listed, the Application is mailed to the Illinois Department of Public Health.
Homeowner-
Contact the licensed contractor, call you local health department or contact the Illinois Department of Public Health.
Fees:
To be included with application - $100.00 Permit Fee and $50.00 Water Sample Fee. Water Sample Fee to be refunded upon receipt of water sample for new well if collected by property owner or well driller.
The following explanations will assist you in completing the application for a permit to construct or deepen a water well.
Land I.D.# -
This included the PIN number, PC number or any other number used by the county to identify the lot. Contact the local health department to determine if this information is required.
Proposed Use -
Domestic = Single family home
Irrigation = Watering, filling a pond or cooling
Commercial = Apartments, schools, factories, office and other similar buildings
Livestock = Farm Animals
Other = Anything not listed above
Directions to Site:
Please Mail To: Livingston County Health Department, 310 E. Torrance Avenue, Pontiac, Illinois 61764
Important Notice: This state agency is requesting disclosure of information that is necessary to accomplish the statutory purpose as outlined under Public Act 85-0863. Disclosure of this information is mandatory.

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

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