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WELLHEAD PROTECTION AREA PERMIT
Permits are available at the City Office Monday - Friday (7am-4pm). SECTION 1 MUST BE COMPLETED PRIOR TO COMMENCEMENT OF WORK
Date of Application
Date of Application
Permit No.
Ordinance 3077
Wellhead Protection Area
Name
Email Address
Address
City
State
Zip Code
Phone Number
Fax Number
Applicant (if different from owner:)
Address
City
State
Zip Code
Phone Number
Fax Number
Email Address
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WELLHEAD PROTECTION AREA
Wellhead Protection Area Map
Will Activity be Located Within 1,000' of Municipal Well
1. Yes
2. No
Brief Description of Work
(Describe the Project or Activity - Attach Additional Sheets if Necessary)
General Contractor
Name
Email Address
Address
City
State
Zip Code
Phone Number
and/or Cell Phone
The applicant hereby grants permission for the Wellhead Protection Administrator or his designee to inspect the property having given twenty-four hour notice. For additional information or questions please contact Laura Bedlan at the Fairbury City Offices 402 729 2476 ext 107.
Signature of Applicant
Date

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