Tooele Health Department
             
Tooele County Health Department
151 N. Main Street, Suite 140 - Tooele, UT 84074
Phone (435) 277-2440 Fax (435)277-2444
eh@tooelehealth.org
Application for Well / Spring Water Permit

Please put N/A for any fields that are not applicable

Permit fee must be paid before permit will be issued.
Permit is only valid for 24 months from date of application.
Any changes must be approved in writing by TCHD.
Additional fees may be required for repeat samples, additional sampling parameter, or lab fee increases.

Date
Owner Name
Owner Phone Number
Mailing Address
Email Address

Site Address or Legal Description
Parcel Number
Subdivision
Lot Number
Well Driller's Name
Phone Number

Individual Well Permit:   $60.00   Item Subtotal:  
$60.00
Chemical Analysis Water Sample Fee:   $335.00   Item Subtotal:  
$335.00
Rush Fee = Addition Fee of $130:   $130.00   Select:   Item Subtotal:  
$0.00
Total:
$395.00
 
Applicant's Signature
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Method of Payment:
 Update Name from Personal/Organizational Information
Name on Account:
Routing Number:
Account Number:
Institution:
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Account Number:
Expiration Date:
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