Well Submital Form

1

Please enter your information on the following screens

First Name

Last Name

2

Address* This field is required.

Street Address

City

Country

3

Township

4

Phone number

Area Code

Phone Number

5

Email

example@example.com

6

Preferred method of contact

Email

Phone

7

OwnershipPlease select if you own or rent your home.

8

NOTE: If you rent and are concerned about your water quality, please complete a nuisance complaint form here:

http://www.clintonhealth.org/forms/nuisance%20complaint%20form.pdf

9

Availability

Morning (9am - noon)

Afternoon (noon - 4pm)

Evening (4pm - 6pm)

10

Any water treatment (ex: UV or Chlorine Treatment, Do Not Include Softeners)?

YESNO

11

If yes, please explain:

12

Can outside tap be used?

YESNO

13

Explain where the outside "tap" is located

14

Are there any children in the household that are under 6 months?

YESNO

15

Water source type?

16

If known, what is the depth of your well?

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