Water Well Construction Application – Van Buren Cass District Health Department

Installing a new or replacement water well, or hooking up to an existing water supply.

Permit For*
Please choose one from the menu (use down arrow for options):
Home Owners Name*
First Last
Home Owners Mailing Address*
Street Address Address Line 2 City State ZIP Code
Home Owners Phone #*
Applicants Phone #
Applicants Name
First Last
Applicants Mailing Address
Street Address Address Line 2 City State ZIP Code
Applicants Email
Applicants Fax #
Property Address*
Street Address Address Line 2 City State ZIP Code
Parcel ID#
County*
Township:
Section:
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*
By typing your own name above below you are voluntarily signing this document electronically, acknowledging and agreeing to its terms.
Comments
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