Ford County Planning, Zoning	Residential Water Well Permit Application
	and Environmental Health	Office Use Only
	100 Gunsmoke, Dodge City, KS 67801	Parcel #:
	Phone:  (620) 227-4670	Permit #:
	Fax:  (620) 227-4717	Location of Proposed Well                        Section                Township             Range
	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                        Stock                             Lawn                                       Monitor	Other If Stock, how many head?                              If Lawn, how many acres?	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
Natural ground slope (direction):  _______________________
#_____ 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 transferrable.  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, itis 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 requirements 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 construction.  I will plug this well if it falls into disuse, becomes unserviceable, or becomes a safety or health hazard.
Owner 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		Water test results
Meets code & article 30 requirements?		Test	Test Range     MCL     Method     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