Skip survey header

Water Sampling Form

Domestic Well Water Sampling Program

The Division of Environmental Health Services (DEHS) has obtained a grant to assess some basic water quality for private wells.  
DEHS would like to take some water samples from your well  for our voluntary Domestic Well Water Sampling  (DWWS) program.

Sampling and test results are provided free of charge.Sampling hours are between 9am-3pm Monday & Friday or Wednesday 9am-12pm .  You do not have to be present to have the sample taken.

Instructions:
  • Completely fill out the Consent form
  • Indicate where the water sample will be taken
  • Sign your name
  • Indicate any special instructions

Please fill out the form below to set up an appointment to have your well water sampled or contact:

Monica Castruita
EHS.CustomerService@dph.sbcounty.gov
800-442-2283
www.sbcounty.gov/dph/dehs
1. Please contact information below *This question is required.
2. What is the water source? *This question is required.
3. Where will the water sample be taken from (must be connected to well)? *This question is required.
4. What is the preferred time for sample collection by the technician (check all that apply) *This question is required.
5. I volunteer to participate in the DWWS program and authorize San Bernardino County DEHS to collect water samples from the property well. *This question is required.
Clear
Signature of
0%