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REQUEST FOR WATER SAMPLES

2. 

4. Applicant Name (Required)

5. Email Address of Applicant (Required)

7. Mailing Address (Required)

9. City

10. State

11. Zip

13. Daytime Phone

15. Rental?

    1. Yes
    2. No

16. Owner Occupied?

    1. Yes
    2. No

17. Any existing water treatment?

    1. Yes
    2. No

19. Site Address (If different than mailing)

21. PAYMENT METHOD (REQUIRED)

    1. MAIL CHECK TO OCHD ENVIRONMENTAL HEALTH P O BOX 8181 HILLSBOROUGH, NC 27278
    2. PAY BY CASH, CHECK, OR CARD WITHIN AT 131 W. MARGARET LN HILLSBOROUGH, NC 27278
    3. CALL 919-245-2378 TO PAY BY CARD

    Payment is required. If payment is not received within 5 business days, this application will be held in pending and discarded after 30 days.

23. TYPE OF SAMPLE(S)

    1. Bacteriologic ($75)
    2. Inorganic ($110)
    3. Nitrate/Nitrite ($75)
    4. Full sample suite ($150) Includes the Bacteriologic, Inorganic and Nitrate/Nitrite samples.

    1. VOC ($150)
    2. Iron bacteria ($75)
    3. Sulfur Bacteria ($75)
    4. Pesticides ($150)

    1. Coal Ash Panel ($100)
    2. Hexavalent Chromium ($100)
    3. Petroleum ($150)
    4. Herbicides ($150)

    Please select which type of sample(s) you are requesting.

25. ACKNOWLEDGMENT

    Water samples may be requested by the owner or tenant of the property. The well head and sampling spigots should be exposed and made accessible. Please do not chlorinate the well before sampling unless instructed to do so otherwise.

    Water samples may be requested by the owner or tenant of the property. The well head and sampling spigots should be exposed and made accessible. Please do not chlorinate the well before sampling unless instructed to do so otherwise.

27. YOUR FULL NAME

    By typing in my name, I authorize the Orange County Health Department to enter the property and to perform the service requested.

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28. 1. Receive an email copy of this form.
29. Email address

    This field is not part of the form submission.

30. Submit

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