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2. Disclaimer

   Information submitted on this form will be sent via unsecured email. To protect sensitive information, do not enter the following items or similar information on this form: Social Security numbers, driver’s license numbers, bank account information, routing numbers, credit card numbers, medical information, passport numbers, and passwords. Please review our privacy policy located at www.jeffco.us/privacy. By submitting this form, you acknowledge and accept the terms listed in the privacy policy.

4. APPLICANT INFORMATION

   Provide your mailing address and contact information.

6. Well Owner First Name
7. Well Owner Last Name
9. Well Owner Address
11. Address Line 2
13. City
14. State
15. Zip Code
16. Country
18. Phone Number
19. Email Address
21. WELL LOCATION INFORMATION

    Provide the location of the well. 

    Note: If the well location information is the same as above, you may skip this section and jump to "Well Construction Information" in this application.

23. Well Owner First Name
24. Well Owner Last Name
26. Address of Well
28. Address Line 2
30. City
31. State
32. Zip Code
33. Country
35. Phone Number
36. Email Address
38. WELL CONSTRUCTION INFORMATION

    If you have the following information, please provide it.

40. Well Permit Number
42. Year of Construction
44. Depth of Well
46. Depth to Water
48. ACKNOWLEDGEMENT & AUTHORIZATION

    YES, I will participate in the Jefferson County Public Health private well water sampling program. I hereby grant my consent to allow my well water sample results to be analyzed by the Jefferson County Environmental Health program staff and the sample results and general location of my well to be published publicly in reports generated through this program. I understand that my personal information, such as my name, the location of my well, the address of my property, and/or the well permit number will not be disclosed to the public.

50. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
52. Electronic Signature
Leave This Blank:


54. 1. Receive an email copy of this form.
55. Email address

    This field is not part of the form submission.

56. Submit

* indicates a required field