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:
$214.00
(Checks Payable
to: Polk County
Public Works)
DATE APPLICATION: ___________________________________
OWNER: PHONE: ____________________________________
ADDRESS:
CELL: ______________________________________
CITY:
STATE: ZIP CODE:
Email:
(permits and certificate of compliance will be emailed when an email is provided)
JOB SITE ADDRESS: TOWNSHIP:
If no site address please provide Geo Parcel #
WELL DRILLER: 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)Served:
Additional Information for drinking water, irrigation, livestock, monitoring wells, etc.
Construction Mate
rial: Type of Pump:
Depth Est. Diameter
Additional Information for Heat Pump / Geothermal
# Holes: Bore 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
ME 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 #______________________
