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Waste disposal well—Application for permit. Application No. _________ State of Idaho Department of Water Resources Application for a Permit To Construct [ ] Modify [ ] Maintain [ ] a Waste Disposal and Injection Well Under the Provisions of Chapter 39 of the Idaho Code 1. Name of applicant _________ Phone No. _________ Post office address _________ 2. Location of well: (If additional wells are also applied for, check here [ ] and list on supplement sheet). _________ ¼ of _________ ¼ of _________ ¼, Section _________, Township _________ N/S, Range _________ E/W, B.M., _________ County. Show well location in section [map omitted] Attach an aerial photo or map which clearly indicates the location of the well with respect to adjacent improvements and section or quarter-section lines. Photo copies are often available from a local ASC Office. 3. Frequency of discharge: Continuous [ ] Seasonal [ ] 4. Maximum rate of discharge _________ GPM _________ CFS _________ Miner's Inches 5. Type of discharge: [ ] Irrigation return flows and/or flood waters [ ] Domestic wastes (sewage) [ ] Industrial wastes [ ] Street runoff waters [ ] Other _________ A. Irrigation return flows and/or flood waters Original source: stream diversion flow [ ] ground waters [ ] flood runoff [ ] Method of irrigation: gravity [ ] sprinkler [ ] Crops irrigated _________ Fertilizers used (type and quantity) _________ lbs/acre Pesticides used (type and quantity) _________ lbs/acre Approximate drainage area _________ acres Settling pond at well: yes [ ] Size: _________ no [ ] Screening structure at well: yes [ ] Size and mesh: _________ no [ ] B. Industrial wastes: Type _________ Treatment prior to injection Chemical or bacteriological analyses available: yes (include) [ ] no [ ] C. Description of well usage, if not covered above _________ 6. Possible alternative methods of disposal _________ 7. Description of the waste disposal well: Diameter _________ inches Depth _________ feet Date constructed _________ Casing: diameter _________ inches; depth _________ feet; perforation depth _________ feet Surface seal: no [ ] yes [ ] Type _________ Depth _________ Well log available: no [ ] yes [ ] (attach) Driller's name and address (if known) _________ 8. Distance to nearest domestic well _________ ft. Which direction from disposal well _________ Depth to ground water _________ feet The locations of nearby producing wells must be identified on the map or photo submitted. Be it known that the undersigned hereby makes application for a permit to construct, modify, alter or maintain a waste disposal or injection well. The above information is true and correct to the best of my knowledge.
Action of the Department of Water Resources I have examined Application no. _________ and said application is hereby _________ subject to the following conditions: _________. Witness my hand this _________ day of _________, _________. _______________ Administrator—Operations Division Instructions for Filing an Application for Permit To Construct, Modify, or Maintain a Waste Disposal and Injection Well The provisions of Title 42, Chapter 39 of the Idaho Code require that any individual who wishes to construct, modify, or maintain a waste disposal and injection well must first apply for and receive a permit to do so from the Idaho Department of Water Resources (previously Water Administration). The law also requires that individuals having existing waste disposal and injection wells must submit an application for continued use prior to January 1, 1974. You may use Form 42-3904 available from the Department, entitled "Application for a Permit to Construct, Modify, Maintain a Waste Disposal and Injection Well" to obtain authority for any of the above items. When complete, the application should be submitted to the nearest District Office of the Idaho Department of Water Resources as indicated on this sheet. Fees provided for in Section 42-3905, Idaho Code, shall accompany all applications. No application to construct a well shall be accepted unless accompanied by a filing fee of _________ dollars ($_____) per application, providing that for any such application covering more than one (1) well there shall be an additional filing fee of _________ dollars ($_____) for each additional well. No fee shall be charged for modification of a well or for renewal or extension of a permit which has been previously issued under the provisions of this act. No fee shall be charged for applications submitted on wells in operation on or before January 1, 1971. All fees received under the provisions of this act are deemed to be non-refundable. You may include in one application all wells under a single ownership that are used to dispose of the same material. Attach extra copies of the form or the supplement sheet (Form 42-3904A) if necessary to describe additional wells. District Offices of the Idaho Department of Water Resources Western District Annex 3—Statehouse Boise, Idaho 83720 (384-2190) Southern District 1041 Blue Lakes Blvd. N. Twin Falls, Idaho 83301 (734-3578) Eastern District 1515 Lincoln Road Idaho Falls, Idaho 83401 (523-7186) Northern District 401 Front Avenue Room 209 Coeur d'Alene, Idaho 83814 (667-6484) All disposal wells must be constructed by a licensed Idaho well driller and the driller is required by Section 42-3912 of the Idaho Code to obtain a certified copy of the owner's permit prior to beginning work.
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