DARKE COUNTY GENERAL HEALTH DISTRICT
300 Garst Avenue
Greenville, Ohio 45331

Phone: (937) 548-4196 Fax: (937) 548-9654

APPLICATION FOR WATER TESTING

PLEASE SEND EVALUATION RESULTS TO:

Name _________________________________________ Phone #__________________

Address ________________________________________________________________

City, State, Zip ___________________________________________________________

LOCATION OF REQUESTED SAMPLE:

Name_____________________________________ Phone # ______________________

Address ________________________________________________________________

City _____________________________________ Township _____________________

Directions: ______________________________________________________________

PARAMETER TO BE TESTED: (please circle)

Total Coliform Bacteria: Y N LABORATORY FEE: $15.00

Lead Y N LABORATORY FEE: $15.00

Nitrate/Nitrite Y N LABORATORY FEE: $30.00

Nitrate Y N LABORATORY FEE: $15.00

Nitrite Y N LABORATORY FEE: $13.00

Iron Y N LABORATORY FEE: $15.00

Fluoride Y N LABORATORY FEE: $25.00

Arsenic Y N LABORATORY FEE: $15.00

OTHER: _______________________ LABORATORY FEE: _______

LABORATORY FEES PLUS $35.00 COLLECTION FEE = TOTAL FEE

TOTAL FEE: ______________

Receipt # (s) __________ __________ __________ __________ __________

ALL FEES ARE NON-REFUNDABLE.

IS THIS SAMPLE FOR A HOME SALE? Yes No

IS THIS SAMPLE FOR A LAND SPLIT? Yes No

IF YES, COMPLETE APPLICATION FOR EVALUATION OF EXISTING HOME SEWAGE SYSTEM.

By signing below, the homeowner/applicant understands that the health department may inspect the components of the private water system from which the water sample is requested. The owner/applicant also understands that upgrades may be required if deemed appropriate and/or necessary in order to protect public healthy or safety per OAC 3701-28-19. If for any reason the appointment needs to be cancelled or rescheduled, you must call at least 24 hours prior to the originally scheduled appointment.

___________________________________ __________________
Applicant Date

___________________________________ __________________
Homeowner or Representative Date

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FOR OFFICE USE ONLY

Location Inspector Date

1^st Sample: _____________ ___________ _________ Satisfactory Unsafe

2^nd Sample: _____________ ___________ _________ Satisfactory Unsafe

3^rd Sample: _____________ ___________ _________ Satisfactory Unsafe

Other Results: ____________________________________________________________

________________________________________________________________________

Notes: __________________________________________________________________

________________________________________________________________________

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DATE OF APPOINTMENT: _____________________ TIME: __________________

LAST REVISED: April 4, 2008

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