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APPLICATION FOR WELL AND PUMP PERMIT
Permit # Date
A permit is requested to: drill a well install a pump A�
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LOCATION:h1 rOh t Lot #
Owner f�- _L me 61�/1yn AddressCi�Y a,41 %Ove Tel
Well Contrctr %u N 6 Add. ����u� Tel
Pump Contrctr 'S(4 X-C Add. Tel --
WELLS (To be completed at time of pump test.,)����
Type of well
Diameter of well
Depth of bed rock
Use
Size of casing
Depth casing into bedrock
Seal been tested? Yes (_) No (_) Date of test.
Depth of well Water -bearing rock
Depth to water
Delivers
GPM for
(how long?)
Drawdown feet after pumping hours at GPM
Date of completion.
Signature of well contractor
PUMPS (To be filled in before installation.)
Name & size of pump
Size of tank
Pump delivers
Type
GPM
Pipe used in well: Cast iron (_) Galvanized (_) Plastic (_)
Sleeve used to protect pipe? Yes (_) No (_) Type well seal
Date
Signature of pump installer
Date water analysis report submitted to Board of Health
Plumbing inspector Wiring inspector
Board of Health