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Tooele County Health Department
151 N. Main Street, Suite 140 - Tooele, UT 84074
Phone (435) 277-2440 Fax (435)277-2444
www.tooelehealth.org
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.
If you have additional documents to send, please email them to eh@tooelehealth.org.
***Start Card or proof of water rights from the Division of Drinking Water
must
be submitted with the application***
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 (optional) = Additional Fee of $130:
$130.00
Select:
Item Subtotal:
$0.00
Total:
$395.00
Applicant's Signature
Payment Information:
Method of Payment:
Update Name from Personal/Organizational Information
Name on Account:
Routing Number:
Account Number:
Institution:
Name on Card:
Account Number:
Expiration Date:
Billing Street Address:
Billing ZIP/Postal Code:
Change Payment Method
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