Polk County Public Works
5885 NE 14th Street
Des Moines, IA 50313
Phone: 515-286-3705 FAX: 515-286-3437
Email: publicworks@polkcountyiowa.gov
PERMIT FEE: $217.00
(Checks Payable to: Polk County Public Works)
DATE APPLICATION: ___________________________________
OWNER: PHONE: _
___________________________________
ADDRESS:
CE
LL: ______________________________________
CITY:
STATE: ZIP CODE:
Email:
(permits
and certificate of compliance will be emailed when an email is provided)
JOB SITE ADDRESS:
T
OWNSHIP:
I
f no site address please provide Geo Parcel #
WELL DRI
LLER:
PHONE:
COMPANY: CELL:
ADDRESS:
CITY: STATE: _____ZIP CODE: _____________
INFORMATION REQUIRED FOR ALL PERMITS:
The proposed well will be: (check appropriate box)
1. New potable water well (serves a private residence)
2. Replacement well (replaces an existing well located on the property)
3. Irrigation/livestock/monitoring well (not connected to house or public water systems)
4. Geothermal well – vertical installation and horizontal installation
* If installation is less than 20' a well permit is not required.
Well Type: (check appropriate box)
Driven Drilled Bored
Structure(s)Serv
ed:
A
dditional Information for drinking water, irrigation, livestock, monitoring wells, etc.
Constr
uction Mate
rial: Type of Pump:
Depth Est. Diameter
A
dditional Information for Heat Pump / Geothermal
# Holes: Bor
e Hole
Depth:
#
Loops: Loop Length:
Loop
Diameter:
Loop Pipe Manufacturer:
NO PERMIT SHALL BE ISSUED UNTIL SUCH TIME THE PROPOSED WELL SITE HAS BEEN PROPERLY FLAGGED AND
APPROVED BY POLK
COUNTY ENVIRONMENTAL HEALTH. IT IS A VIOLATION OF THE 567 I.A.C. 49 AND
CHAPTER II OF THE POLK COUNTY HEALTH
REGULATIONS TO COMMENCE DRILLING WITHOUT A VALID PERMIT.
WATER ANALYSIS WILL NOT BE TAKEN AND OCCUPANCY OF THE PREMISES WILL NOT BE APPROVED WITHOUT PRIOR
SUBMITTAL OF A
WELL DRILLER’S LOG. A WATER ANALYSIS AND DRILLER’S LOG MUST BE SUBMITTED PRIOR TO FINAL
INSPECTION. ALL PARTS OF THE
SYSTEM MUST BE ACCESSIBLE FOR THE FINAL INSPECTION.
I HAVE REVIEWED AND UNDERSTAND THE AFOREMENTIONED REQUIREMENTS. ALL INFORMATION SUPPLIED BY
M
E IS TRUE AND
CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF.
Printed Name of Applicant or Owner Signature of Applicant or Owner
WELL PERMIT APPLICATION
GPM/Hour:
Permit #______________________
