Ford County Planning, Zoning  Residential Water Well Permit Application
 and Environmental Health  Office Use Only
100 Gunsmoke, Dodge City, Ks. 67801 Parcel#:________________________________
Phone: (620) 227-4739 Permit#________________________________
 Fax: (620) 227-4717  Location of Proposed Well    Section:(__)  Township (__) s    Range (__)w
 http//www.fordcounty.net  
  Owner Information  Applicant Information (if different)
  Name of Applicant  Name of Applicant
  Mailing Address Mailing Address
City                                    State                  Zip Code   City                          State                                        Zip Code
  Telephone#                                                 Email address   Telephone#                                                 Email address
Intended Use (circle applicable use)
Domestic                          Other _______
Stock                           If Stock, how many head?______
Lawn                           If Lawn, how many acres?_____
Monitor 		Draw plan here (include dimensions, ground slope, wastewater systems, water wells, natural bodies of water, corrals, outbuildings, and other potential sources of
contamination. Please include an arrow indicating north):
Well Information                 
 Well location (street address):
 Distance of well from property lines (insert on next line):
 Feet from ____N ____S            Feet from ____E____W
  If less than 200 feet from natural body of water.
  how many feet _____river_ ____stream _____pond _____lake
  #______abandoned wells present
  #______feet from septic system
  Well driller name:
  Well driller address:
  Driller phone #
  Your Responsibilities:
  1. Drill well AFTER an application has been approved.
  2. Chlorinate well before final assembly.
  3. Well permit is not transferable. Fees are non-refundable.
  4. The application is good for one year from date of application
 5. Construct well according to applicable county sanitary code and KS Article 30. If not, it will be plugged at applicant's expense.
 6. You may be prosecuted under state and county laws for failure to comply with the laws governing this application.
7. The issuance of permit does not guarantee the well will satisfactorily operate. 
 8 This application does not relieve you from responsibility to other federal, state, or local agency's requirements.
 9.  Contact this office within 30 days after construction to submit a Well Driller's Log (WWC-5), and we will complete a final inspection.
 10. If well falls into disuse, becomes unserviceable or a safety/health hazard, it is your responsibility to plug the well.
Owner statement: I certify the information presented to Ford County on this application to be factual and true. I further certify, if this application is approved, this well will be constructed in accordance with the system's permit requirements, the requiremtnts of the county sanitarian and the county environmental code. In addition, the county sanitarian will be called for final inspection within a month of the completion of consturction. I will plug this well if it falls in disuse, becomes unserviceable, or becomes a safety or health hazard.
Owner/Applicant signature:______________________________________________________________Date:_____________________________________
This application and the attached plan are approved for construction. This application expires after one year.

Ford County Sanitarian signature: ________________________________________________________Date:
 Final Inspection                            Y/N Comments      
Waterr Test Results
Meets code article 30 requirements? Test      Test Range      MCLMethod       RESULTS       Safe/Unsafe*
KDHE approved seal? Chlorine (CI2)     Presence            NA           DPD-1       
Casing 12 above surface?  Coliform Bact.     Only +/-             Neg          Collilert
Water sample taken? 

Fecal Coliform     Only +/-            Neg     Collilert
Well approved? Nitrate(NO3 N)   0 to 30.0 mg/L*     10 mg/L      H355
Inspected by:     MCL is the EPA maximum recommended contaminate level. 
Comments:  *Consult our office for methods of treating unsafe water.
Well:                                        Latitude                                                                                                      Longitude  
Driveway:                               Latitude                                                                                                     Longitude   
Septic:                                     Latitude                                                                                                       Longitude