Well and Pump Permit

CITY OF HAVERHILL BOARD OF HEALTH

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 MASSACHUSETTS CERTIFIED LABORATORY.

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________________

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