Form IL482-0620 "Application for Permit to Construct, Modify or Abandon a Water Well" - Illinois

What Is Form IL482-0620?

This is a legal form that was released by the Illinois Department of Public Health - a government authority operating within Illinois. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • The latest edition provided by the Illinois Department of Public Health;
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Download a fillable version of Form IL482-0620 by clicking the link below or browse more documents and templates provided by the Illinois Department of Public Health.

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Download Form IL482-0620 "Application for Permit to Construct, Modify or Abandon a Water Well" - Illinois

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State of Illinois
Illinois Department of Public Health
APPLICATION FOR PERMIT TO CONSTRUCT, MODIFY OR ABANDON A WATER WELL
DO NOT SEND CASH
PERMIT FEE: $____________
Local Health Department
FOR OFFICIAL USE ONLY
Address
TYPE OR PLACE
LABEL WITH NEEDED
City/State/Zip Code
INFORMATION
Phone Number
Fax Number
If this box is checked, the permitting authority plans to complete a comprehensive inspection and shall be notified of any scheduling changes.
Owner
Owner Phone Number
Mailing Address
Owner Fax Number
City
State
Zip Code
Well Site:
Property Address
Township Name
County Property Identification #
Zip Code
City
Lot #
Subdivision
County
Township
Section
Range
1/4 of the
1/4 of the
1/4
Directions to the Site
WATER WELL INFORMATION
Permit To:
well type:
Dug
Driven
Bored
Drilled
Construct
Deepen
Repair
Seal
for a:
B. Semi-Private Well
A. Private Well
D. Non-Potable Well
C. Non-Community Well
use:
Commercial
Residential
Livestock
Irrigation
Other
Complete if B or C checked:
Number of people served
Type of facility
(If C is checked, an application For Permit to Construct, Alter or Extend a Non-Community Public Water Supply must be submitted.)
Check if anticipated pumping capacity is greater than 100,000 gallons per day.
WELL CONSTRUCTION OR ABANDONMENT INFORMATION 1. If well log is available, attach the log to this form.
2. If well log is not available, well must be sealed from bottom to top.
in/ft
ft
in/ft
ft
Size
depth
Size
depth
Borehole :
Aquifer :
Sand & Gravel
Limestone
Sandstone
Other
Casing :
Type
Size
in/ft
Estimated Amount
ft
Liner:
Type
in/ft
ft
Size
Estimated Amount
Top of Liner
Type Seal
Bottom of Liner
Type Seal
ft
ft
Existing water well on property?
Is it to Code?
Will it be used?
Yes
No
Yes
No
Yes
No
Existing well to be sealed:
Well in building
Well in pit
Pit retained
Pit eliminated by:
Contractor
Owner
Is well free of obstruction?
Yes
No
If No, at what depth is obstruction?
ft
FOR OFFICIAL USE ONLY
Construction Permit Number
/
/
FIPS Code
Number
Year
Sealing Permit Number
Approved by
Date
/
/
FIPS Code
Year
Number
Page 1 of 2
Form Number IL482-0620
State of Illinois
Illinois Department of Public Health
APPLICATION FOR PERMIT TO CONSTRUCT, MODIFY OR ABANDON A WATER WELL
DO NOT SEND CASH
PERMIT FEE: $____________
Local Health Department
FOR OFFICIAL USE ONLY
Address
TYPE OR PLACE
LABEL WITH NEEDED
City/State/Zip Code
INFORMATION
Phone Number
Fax Number
If this box is checked, the permitting authority plans to complete a comprehensive inspection and shall be notified of any scheduling changes.
Owner
Owner Phone Number
Mailing Address
Owner Fax Number
City
State
Zip Code
Well Site:
Property Address
Township Name
County Property Identification #
Zip Code
City
Lot #
Subdivision
County
Township
Section
Range
1/4 of the
1/4 of the
1/4
Directions to the Site
WATER WELL INFORMATION
Permit To:
well type:
Dug
Driven
Bored
Drilled
Construct
Deepen
Repair
Seal
for a:
B. Semi-Private Well
A. Private Well
D. Non-Potable Well
C. Non-Community Well
use:
Commercial
Residential
Livestock
Irrigation
Other
Complete if B or C checked:
Number of people served
Type of facility
(If C is checked, an application For Permit to Construct, Alter or Extend a Non-Community Public Water Supply must be submitted.)
Check if anticipated pumping capacity is greater than 100,000 gallons per day.
WELL CONSTRUCTION OR ABANDONMENT INFORMATION 1. If well log is available, attach the log to this form.
2. If well log is not available, well must be sealed from bottom to top.
in/ft
ft
in/ft
ft
Size
depth
Size
depth
Borehole :
Aquifer :
Sand & Gravel
Limestone
Sandstone
Other
Casing :
Type
Size
in/ft
Estimated Amount
ft
Liner:
Type
in/ft
ft
Size
Estimated Amount
Top of Liner
Type Seal
Bottom of Liner
Type Seal
ft
ft
Existing water well on property?
Is it to Code?
Will it be used?
Yes
No
Yes
No
Yes
No
Existing well to be sealed:
Well in building
Well in pit
Pit retained
Pit eliminated by:
Contractor
Owner
Is well free of obstruction?
Yes
No
If No, at what depth is obstruction?
ft
FOR OFFICIAL USE ONLY
Construction Permit Number
/
/
FIPS Code
Number
Year
Sealing Permit Number
Approved by
Date
/
/
FIPS Code
Year
Number
Page 1 of 2
Form Number IL482-0620
State of Illinois
Illinois Department of Public Health
APPLICATION FOR PERMIT TO CONSTRUCT, MODIFY OR ABANDON A WATER WELL
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 dry wells 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
Storage/Pump Cycle
gpm
gallons
WORK SCHEDULE*
Estimated scheduled date to start work on water well (MM/DD/YR):
*NOTE:
Illinois Water Well Construction Code, Section 920.130 g) Notification. Any person who contructs 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
Print Name of Licensed Water Well Contractor
License Number
City, State, Zip Code
Address
Cell Phone Number
Fax Number
Office Phone Number
Date
Signature Licensed Water Well Contractor / Property Owner
Licensed Water Well Pump Installation Contractor
Print Name of Licensed Water Well Pump Installation Contractor
License Number
Address
City, State, Zip Code
Office Phone Number
Fax Number
Cell Phone Number
Date
Signature Licensed Water Well Pump Installation Contractor / Property Owner
COPIES
THREE COPIES ARE RETURNED TO THE LOCAL HEALTH DEPARTMENT WHERE THE PERMIT IS ISSUED
One copy is retained by the health department where the permit is issued
One copy of the approved application is sent to Illinois State Water Survey
One copy is sent to the water well contractor
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 the information is mandatory. This form has been approved by the Forms Management Center
Page 2 of 2
Form Number IL482-0620
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