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NEW WELL NOTIFICATION FORM <br />PERMIT NUMBER: l 975-3215 <br />This form must be submitted to the Department of Natural Resources, Division of Waters prior to <br />the connection of the well to the water supply system. Please mail the form to: <br />DNR Waters 1200 Warner Road St. Paul MN 55105; or fax to: 651-772-7977. <br />Please be sure to include a copy of the Deft. of Health's Well and Boring Record form. <br />Installation Number: <br />Urilque Number (from Well and Boring Record form): <br />Location of Well (include a map and air photo showing location): <br />Capacity of Well and expected pumping rate: <br />Status of Commitments made in approved Emergency and Conservation Plan: <br />Res and only to those that a I to ou <br />Monitoring: <br />Unaccounted for Water (if over 10°.'0): <br />Residential Gallons per capita demand ~(if over 75 GPCD): <br />Alternative Water Sources (if alternative sources were agreed to): <br />Preventive Maintenance: <br />Total Per Capita Use (if not decreasing): <br />Peak Demand (if ratio is over 2.6): <br />Conservation Rate Structure (if rate changes were agreed to): <br />Education Efforts: <br />Retrofitting Programs: <br />Other Commitments: <br />Submitted by: Date: <br />Title: Phone #: <br />Address: <br />Signature: <br />c: Area Office to forward completed form to the SWUDS Database Manager upon receipt <br />