APPENDIX A: PRIVATE WELL OPERATION PERMIT

PROPERTY OWNER: ________________________________________________________________

STREET ADDRESS: _________________________________________________________________

PURPOSE OF WELL:   Private/Domestic ________   Yard/Garden ________

                  Industrial ______________   Other ______________

IS PROPERTY SERVED BY THE MUNICIPAL WATER SYSTEM? _________________________

DO ANY CROSS-CONNECTIONS EXIST? _______________________________

DOES WELL MEET EXISTING STATE CODES? ________________________________________

IS A WELL CONSTRUCTION REPORT ON FILE WITH THE DNR? _______________________

WELL INSPECTED BY? _______________________________________________

WELL INFORMATION: DEPTH ______   DIAMETER ____   CONSTRUCTION DATE _______

WATER SAMPLES REQUIRED: A minimum of two bacteriological samples taken at least two weeks apart are required, and the results must be attached to the application. Additional test(s) may also be required in some situations.

SAMPLE #1: DATE ________________________ RESULTS _______________________________

SAMPLE #2: DATE ________________________ RESULTS _______________________________

ANY OTHER SAMPLING REQUIRED? ________________________________________________

RESULTS: _________________________________________________________________________

WELL OPERATING PERMIT APPROVED?   YES _______    NO _________

RENEWAL DATE: (5 YEARS) ________________________________

PERMIT FEE: an amount which can be found at the office of the Village Clerk

APPLICANT’S SIGNATURE         DATE:

AUTHORIZED SIGNATURE         DATE:

(Ord. passed 1-9-2002)