CITY OF
Permit No.____________ Date _____________________
APPLICATION FOR WELL AND PUMP PERMIT
Prior to filing this application, written approval must be obtained from the Haverhill Water Department.
THE WATER DEPARTMENT HAS NO OBJECTION TO THE ISSUANCE OF A WELL PERMIT FOR THE ADDRESS BELOW:
______________________________ _________________
AUTHORIZED SIGNATURE DATE
PLEASE NOTE: BOARD OF HEALTH REGULATION REGARDING DUAL CHECK BACKFLOW PREVENTERS ON ALL NEW OR REPLACEMENT WELL PUMPS. (REGULATION ATTACHED)
ORIGINAL WATER ANALYSIS REPORT SHOULD BE FROM A
Application is hereby made for a permit to drill ( ) or repair ( ) a well. Application is also made to install ( ) major renovation ( ) or major repair ( ) of pump system.
Lot No. __________________ Street Address __________________________________
Owner __________________________ Address __________________________________
Well Contractor_________________ Address __________________________________
Pump Contractor_________________ Address __________________________________
WELL CONTRACTOR (THIS SECTION TO BE FILLED IN AT TIME OF PUMP TEST)
Type of Well ____________________ Well Used for ____________________________
Diameter of Well ________________ Size of Casing ___________________________
Depth of Bed Rock _______________ Depth of Casing into Bed Rock ____________
Was Seal Tested? Yes ( ) No ( ) Date of Testing ____________________
Depth of Well ___________________ Well Ended in What Material ______________
Depth to Water __________________ Delivers _______________ Gallons/per/Minute
Drawdown _______ feet after pumping ____ hours at ____ GPM. Sketch map of
well location with tie down lines on reverse side of this form.
Date of Completion ________________ ________________________________________
Well Contractor's Signature
PUMP INSTALLER (THIS SECTION MUST BE FILLED IN BEFORE INSTALLATION)
Size and Name of Pump _______________Type of Pump_____________________
Water Pump Delivers ____________ GPM Size of Tank ____________________
Pipe material used in Well: Cast Iron ( ) Galvanized ( ) Plastic ( ). If
plastic test strength _____________________
Well pit ( ) or Pitless adapter ( )
Was sleeve used to protect pipe? Yes ( ) No ( )
Type or Name of well Seal ______________________
Date ____________________________ _________________________________________
Pump Installer's Signature
Date water analysis report submitted to Board of Health ____________________
Date release given to owner of record and Building Inspector________________