Upper Bern Township PO Box North 5 th Street Shartlesville, PA Phone: Fax:

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1 Permit Procedure for Water Well Installation The Township is responsible for preventing public health hazards resulting from improper well placement and inadequate well construction. All new wells shall be constructed to the standards of the Upper Bern Township Ordinance Number , also known as the Upper Bern Township On-Lot Water Supply Ordinance and the following procedures are to be followed in the application/ permit process for well installations. 1. A permit to install any well is required prior to commencement of construction of the well or of any building which will be served by the well. 2. An application for a well permit must be made on forms approved by the township. The well permit will not be approved without the application for On-Lot Sewage if On-Lot Sewage is used on the property. 3. Upon submission of a completed permit application, the township shall issue or deny a permit within seven (7) working days. (Saturday, Sundays, and Holidays are excluded) 4. In the event that the permit application is found imcomplete, the application will be returned and the review period shall be seven (7) days from the Township s receipt of the supplemented or amended information. 5. For community, municipal, or public water supplies, the applicant shall contact the Township Office at The application for well permits must be signed by a Township- approved well driller and shall be in the name of the real property/ equitable owner. If the application is made by an equitable owner, a copy of the sales agreement must be attached to the well application. 7. The following information must be included on the plot plan: Property Lines, Adjacent Streets, Lot Dimensions (in feet), North Arrow, Slope Direction (downhill), Proposed House, Well Location, Existing Structures and Existing or Proposed Septic Systems. Stream, flood plains, wetlands, and ponds identified on the property or adjacent to the site. 8. Distance (in feet) from the well to applicable setback items and sources of pollution must be shown on the drawing (plot plan). Distances from two (2) nonparallel adjacent property lines to the proposed well must also be shown on the plot plan. (See attached sample plot plan) The distance to the proposed or existing on-lot sewage disposal systems, whether on the lot or adjacent to, must be shown on the plan. Upper Bern Township Well Permit Page 1

2 9. Upon approval of the Water Well Permit Application, the Building Inspector will return the signed Water Well Permit and four (4) copies of the Water Well Completion Form. 10. Upon posting of the Water Well Permit at the site, the Well Driller may begin water well construction. 11. Following required water testing, Well Driller should complete Water Well Completion Form and submit four (4) signed original copies to the township. 12. Upon approval by the Building Inspector, one (1) original copy of the Water Well Completion Form will be returned to the applicant. A permit is neither a contract for, nor a guarantee of, satisfactory water quality or satisfactory water quantity. A permit is not considered to be a final approval to use the well, not is it a guarantee that final approval will be granted. The well permit shall expire one (1) year from the date of issuance if construction of the well and the structure that it serves has not commenced within that time. Upper Bern Township Well Permit Page 2

3 Basic Requirements for Water Well Installation If the features listed below are present or proposed on the property or adjacent properties, locate on plan and give distance from the proposed well to specific feature: Feature Individual Primary or Replacement or Replacement On-Lot Sewage Disposal Systems (On or Adjacent to the subject property) Community On-Lot Sewage Disposal Systems (On or Adjacent to the subject property) Septic Tanks, Aerobic Tanks, Sewage Pump Tanks, Holding Tanks Surface water features, such as streams, lakes, ponds (detention/fire), swales, ditches, storm drains, infiltration pits. Includes wetlands, springs and seeps. Farm silos, barnyards, manure pits or tanks, or other storage Minimum Distance Required (in feet) areas of animal manure. (potable domestic wells only) Any external fuel storage facility 50 Principle Building or Structures 15 Road Right-of-Way 15 Driveway 15 Off-Street Parking 15 Property Boundary Lines 25 Sewer lines or drains carrying domestic sewage (except when the sewer line is cast iron pipe with either watertight lead caulked joints or joints filled with neoprene gaskets, or if solvent welded Schedule 40 (or SDR equivalent) or better polyvinylchloride (PVC) pipe.) Any other source of pollution (such as graveyards, cemetaries, fertilizer/ chemical storage buildings used to contain materials deemed to be hazardous for human consumption.) (10) Case by case basis Please complete the attached plot plan. The following information must be included in your sketch of the plot plan on the Well Permit Application Form: 1. Property Lines 2. Reference to North 3. Adjacent Streets 4. Direction of Slope (downslope) 5. Lot Dimensions (in feet) 6. Floodplains, wetlands, streams if located on property or adjacent to the property. Upper Bern Township Well Permit Page 3

4 Plot Plan Location of Improvements Submit a plot plan of the boundary of the property, to scale, showing the following improvements: 1. Location of all existing and proposed structures and buildings. 2. Septic Systems (tanks and drain fields) 3. All public and private roads that border the property 4. All streams, ponds, etc. 5. Driveways and parking, loading areas, etc. I hereby certify that the proposed work is authorized by the owner of record and that I am or have been authorized by the owner to make this application as his or her authorized agent and that we agree to conform to all applicable laws of jurisdiction. I also certify that I have read the supplemental forms outlining inspection requirements and procedures and agree to comply. Signature Date Upper Bern Township Well Permit Page 4

5 Water Well Permit Application Applicant: Mailing Address: Site Address: Tax Parcel Number: Lot Number: Subdivision: Well Drilling Company: Address: Type of Well: o o o New Well 2 nd Well Other please explain: Applicant Signature: Well Driller Signature: Date: Date: Township Use Only Permit Fee: Issue Date: Approved by: Notes: Upper Bern Township Well Permit Page 5

6 Installation of a Subsurface Water Well Pursuant to Application for Sewage Disposal System number a permit is hereby issued to: Name of Applicant UBT Water Well Permit # Telephone Number Address of Applicant Property Address of Site for Sewage Disposal System This permit issued under the provisions of the Upper Bern Township Water Supply Ordinance (UBT Ordinance # ) and is subject to the following conditions: 1. A permit is neither a contract for, nor a guarantee of, satisfactory water quality or satisfactory water quantity. A permit is not considered to be a final approval to use the well, nor is it a guarantee that final approval will be granted. 2. This permit may be revoked for the reasons set forth in the Upper Bern Township Ordinance # The Well Driller MUST complete the Water Well Completion Form, Issued as part of this permit, and the applicant must sign and submit the Form to the Township Office before Authorization to utilize the well or connect the well to the building is granted. 4. The well permit shall expire one (1) year from the date of issuance if construction of the well and the structure that it serves has not commenced within that time. The said permit shall expire, and a new permit shall be obtained prior to the commencement of said construction or installation. Additional Conditions: Keep this permit for future reference. 1. Inspections require 48 hour prior notice. Phone Skip Cross 2. Minimum Inspection Requirements: Initial Stake Out- A stake or other semi-permanent monument shall be placed at the location of the Well as identified on the Permit Application. Final Placement- during final inspection of the On-Site Sewage Disposal System or Prior to the final approval for connection to the public sewage disposal system. 3. Submission of Water Well Completion Form. TO BE POSTED AT THE BUILDING SITE Upper Bern Township Well Permit Page 6

7 Well Permit Number: Water Well Completion Form To be completed by the Well Driller Applicant: Mailing Address: Site Address: Tax Parcel Number: Lot Number: Subdivision: Well Drilling Company: Address: Type of Well: o New Well o 2 nd Well o Other please explain: Well Installation Information: Well Depth (Total): ft Date Well Drilled: Diameter of the Well: in Casing Material: Casing Depth: ft Bags of Grout: Type of Grout: Static Water Level: ft Pump Installation Date: Pump Depth: ft Well Yield: GPM Method of Volume Testing: WATER QUALITY RESULTS ph: Nitrates: Fecal Coliform: Total Coliform: Applicant Signature: Date: Well Driller Signature: Date: Enforcement Officer Signature: Date: Upper Bern Township Well Permit Page 7