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Water Sample Application

  1. Type(s) of Sample Requesting

  2. Instructions

  3. (Subdivision, Mobile Home Park, and Lot Number)

  4. Are there dogs at the property?

    If dogs are present, they must be restrained at the time of inspection.

  5. Bacteria Sample Information

    A bacteriological sample may only be taken from a properly protected well. The $30.00 fee will not be refunded if your well is not properly constructed and cannot be sampled. However, if the well construction is brought up to minimum standard within one year from the application date, no additional fee will be charged for a bacteriological sample.

  6. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

  7. If a record card cannot be found by the Richmond County Health Department please upload a drawing of the well, house and septic tank locations.

  8. Leave This Blank:

  9. This field is not part of the form submission.