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This job status form is required according to Ohio Administrative Code Rule 3701-28-03 O effective April 1 2011. Is this installation for Date you completed this portion of the work New Construction Alteration Briefly list all work completed - Examples drilled well set pump installed pressure tank installed UV disinfection system COMPLETION FORM - Record all information of work completed The completion form portion documents the specific materials placement and installation methods used to complete the work. Water pipe/line Material used outside foundation ASTM Standard Material used inside foundation Service Connections Backflow Protection Devices and Yard Hydrants No. of Service Connections Yard hydrants Installed Backflow Protection Devices installed ASSE Frost-free Sanitary meets ASSE 1057 Pressure Tanks Location of Pressure Tank NSF 61 Approved Yes No Pressure Relief Valve Installed Location of Sample Port Continuous Disinfection UV Chlorine Iodine Ozone Systems must meet the requirements in OAC 3701-28-15 Installed HEA 5239 Rev 03/2011 If Yes complete the Continuous Disinfection Job Status / Completion Form.. PRINT FORM Ohio Department of Health JOB STATUS / COMPLETION FORM Well-Pump-Distribution PERMIT INFORMATION must be completed when submitting for the Job Status or the Completion Form portions Private water systems contractor Registration number Address of property Phone County Permit JOB STATUS The job status portion is used to document the stages of completion for the private water system. The job status form must be completed and submitted in person by fax or by email to the local health district within ten 10 business days of completion of the portion of work completed by the private water systems contractor noted above. This job status form is required according to Ohio Administrative Code Rule 3701-28-03 O effective April 1 2011. Is this installation for Date you completed this portion of the work New Construction Alteration Briefly list all work completed - Examples drilled well set pump installed pressure tank installed UV disinfection system COMPLETION FORM - Record all information of work completed The completion form portion documents the specific materials placement and installation methods used to complete the work. This form must be completed and returned to the local health district prior to final approval of the private water system* This completion form is required according to Ohio Revised Code 3701. 34 3701. 44 and Ohio Administrative Code 3701-28-03 P and must be submitted within thirty 30 days of completion of work. Pitless Adapter or Unit Pitless Unit Style Manufacturer Clear-way Pull-through Other specify Depth below grade Method of cutting hole in casing ft. / in* Pitless Attached to Method of attachment to casing Original Casing Casing Extension Casing Type used for Extension if applicable Type of Original Existing Well Casing PVC Steel Thickness in* Final casing height above finished grade inches Make and model of coupling device if applicable Pump Depth of pump setting or intake Type Submersible Jet Hand Pump ft..

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