New Payment Requested Paid Issued Denied

Residential Commercial/Industrial

Last Name *

Application Fee

Begin typing Address and select from the populated drop-down *

Water System NJ State Permit #

Name *

Certification

Water System to Serve *

Specify What Type (if Other)

First Name *

The undersigned agrees to alter the aforedescribed water supply in accordance with the provisions of N.J. State Department of Environmental Protection Standards for the Construction of Public Non-Community and Non-Public Water Systems, and/or the provisions of N.J.A.C. Title 7:9-9.1 Sealing of Abandoned Wells.

Construct A Potable Water

Applicant Details

Email *

Application Fee

Phone #

Type of Repair/Alteration

Licensed Well Driller Details

Email

Address 2

ZIP *

Property Owner Details

Mailing Address *

N.J. State Well Driller’s License #

Other Type of Permit

Any repair/alteration of a well and/or the pump will require the well be brought up to current code standards, i.e., 50 foot casing, a pitless adaptor and well cap, and raising the well head above ground. Re-drilling or extension drilling will require the well to be locally re-certified by the well driller.

Replacement or Extension of Casing

Conversion to Pitless Adaptor

Phone Number *

Examining Board Special Plumbers License #

The following alterations require that the actual on-site work shall be under the supervision of a person in possession of a valid license issued by the N.J. State Well Drillers’ Examining and Advisory Board: (Select Appropriate Boxes)

Phone #

Address *

Name *

Email

City, State, ZIP *

Signature *

Abandonment/Sealing of Well

City *

State *

Well Permit: $50

Redrilling or Extension Drilling of a Well