Water Well Construction Application Installing a new or replacement water well, or hooking up to an existing water supply. APPLICATION TO INSTALL A PRIVATE OR TYPE III WATER SUPPLY SYSTEM Permit For*Please choose one from the menu (use down arrow for options):Well - New Construction ($250.00)Well - Existing/ Replacement ($250.00)Well - Hook-up to Exisiting ($250.00)Well - Business/ Migrant ($250.00)Well - Renewal* within 6mo of expiring & no changes needed ($125.00)Well - Type II ($400.00)Home Owners Name* First Last Home Owners Mailing Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Owners Phone #*Applicants Phone #Applicants Name First Last Applicants Mailing Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Applicants Email Applicants Fax #Property Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Parcel ID#County*CassVan BurenTownship:AlmenaAntwerpArlingtonBangorBloomingdaleCalvinColumbiaCovertDecaturGenevaHamiltonHartfordHowardJeffersonKeelerLa GrangeLawrenceMarcellusMasonMiltonNewbergOntwaPaw PawPennPine GrovePokagonPorterPorter (N)Porter (S)Silver CreekSouth HavenVolinaWaverlyWayneSection:Subdivision Name:Lot #:Proposed Well Driller's Name:***SCALED DRAWING of Proposed Well Location:(Drawing shall include dimensions to permanent landmarks and any known sources of contamination. Required for application submission and permit approval.)Max. file size: 50 MB.Applicant's Signature NameThis field is for validation purposes and should be left unchanged.
