A “Setback Reduction Form” shall contain the following:

1. (a) Name of property owner;

2. (b) Location of property, including, as applicable; and

   1. (1) Street address;
   2. (2) Subdivision name and lot number; and
   3. (3) Town tax map number and lot number;
3. (c) Reason for alternate location;
4. (d) If applicable, methods of construction used for construction of wells with reduced setbacks, as specified in We 602.14;
5. (e) A sketch map of the on lot well location indicating exact distances to at least 3 permanent reference points;

6. (f) The actual setback distances from the alternate location to potential observed sources of contamination, including but not limited to:

   1. (1) On-site and off-site septic system tanks and effluent disposal areas; and
   2. (2) Property boundaries;
7. (g) The property owner’s signature and date; and
8. (h) The water well contractor’s name and license number.

Source. (See Revision Note at chapter heading for We 600) #12083 eff 3-1-17