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INDIVIDUAL
WATER SUPPLY SYSTEM APPLICATION (LOCATION
AND DESIGN)
BLOCK______________ LOT_______________ Property
address_______________________________________________________________ Homeowner’s name__________________________________
Phone_____________________ Date Submitted____________________________________
Applicant__________________________________________
Phone______________________ Signature of
Applicant___________________________________________________________ Reason for
Well________________________________________________________________ _____________________________________________________________________________
DESIGN DATA Type of well __________________________________Estimated
Depth________________________ Depth of Casing_______________________________ Diameter of
Casing______________________ Method of Sealing_____________________________ Storage
Facilities________________________ Pumping Equipment___________________________
Purification Facilities____________________ ATTACH A SCALED PLOT PLAN OF THE PROPERTY TO BE SERVED,
SHOWING THE FOLLOWING: Size of lot, location of all buildings, location of proposed
individual water supply system, location of sewerage facilities, elevations,
water courses, and the location of any adjacent property septic systems that are
within 150 feet of the proposed well. ______________________________________________________________________________
CERTIFICATE
OF QUALIFIED PERSON This is to certify to the Board of Health of the Township of
Mendham that the undersigned has prepared or examined the within application and
accompanying plan and specifications and that such application and data are in
compliance with Standards for the Construction of non-public and public
non-community water systems N.J.A.C. 7:10-3.10 through 7:10-3.93 and Ordinances
of the Township of Mendham to regulate and control the location, construction,
and use of Individual Water Supply Systems and providing for the violation
thereof. Signature_________________________________________ P.E. License #_____________________ Firm_____________________________________________Phone____________________________
(Seal) or- Name of Well Driller_______________________________
Phone____________________________ Address__________________________________________ License #_________________________ |
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