Private Well Initiative - Water Sampling Results Tool Place Holder | Department of Health

Water & Sewer Application Request for Foster Care Providers

Step 1: Info Form

Step 2: Confirmation

Step 3: Payment

DCFS Mailing Information

DCFS Case Manager Name

Address

Address 2

City

State

Zip

Applicant Information

*Denotes a required field.

*First Name

*Last Name

*Address

Address 2

*City

*State

*Zip

*Email

*Phone

*Parish

Is the location of the well/property being tested the same as the mailing address?

How would you like to receive your testing results?
Email Standard Mail Both

Well/Property Location

Enter the property owner's information below:

*Denotes a required field.

*Physical Address

Physical Address 2

*City

*State

*Zip

*Parish