Well Contractor Registration

Department of Health · South Bend, Indiana

Editable official PDF

Edit the agency’s original form, save your draft, attach documents, and review your completed PDF before signing or ordering delivery.

Print and mail service is available for your prepared packet. Review the destination and the agency’s acceptance requirements before ordering. Government payment is separate from document and postage charges.

Applicant fields are mapped to the source PDF. Agency-only fields are reserved.

Official form and instructions Pay the agency directly

Your application steps6 steps · Department of HealthView steps

1Prepare your answersComplete here
Edit and save your answers on the official PDF.
Official source
2Add supporting documentsComplete here
Attach the supporting records listed by the agency. Check that every page is legible and complete.
- Provide the $10,000 surety bond payable to St. Joseph County Department of Health. Well drillers must attach copies of DNR water-well drilling licenses.
3Review and signPrepare here, finish outside
Complete each applicable applicant signature after reviewing the full declarations. Required notary, professional and witness signatures remain separate.
4Choose paymentPrepare here, finish outside
$200/year well contractor registration, plus any applicable mailing or processing charges. Government fees are separate from the optional prepared PDF and postage. Review the exact amount and recipient before authorizing a check.
Pay the agency directly
5Submit or order deliveryPrepare here, finish outside
Provide the $10,000 surety bond payable to St. Joseph County Department of Health. Well drillers must attach copies of DNR water-well drilling licenses. The original PDF is available to prepare the application. The official payment form instructs users to submit their application through DocuSign first. For a paper/PDF filing, coordinate payment with the department before using that payment-only page.
Official submission instructions
6Keep your receiptComplete here
Save your agency confirmation and payment receipt. Track any mailing from My applications. Delivery does not mean the agency approved your application.

Official requirements and sources

Well Contractor Registration
Exact original PDF, applicant fields, signature blocks and printed instructions reviewed.
Official fee schedule and accepted payments
Expressly verifies check payee, mail instruments and processing charges; does not accept personal checks.
Current department fee schedule
$200/year well contractor registration, plus any applicable mailing or processing charges.
Environmental Health current contact
Current page gives 8th Floor and mailto:envirohd@sjcindiana.gov; public phone 574-235-9750 option 6.
Department contact page
County-City Building 8th and 9th Floors, 227 West Jefferson Boulevard, South Bend IN 46601; Mishawaka office closed June 20, 2025.
Official payment-only form
Instructs payment after the DocuSign application; this page is not a substitute for submitting the application.

Complete your application

Required fields are marked *. Fields follow the agency’s published form. Save your work before leaving this page.

Fill in the official form

Select a highlighted blank and type directly. Use Field list for larger controls and any answers that need a continuation page.

Page Zoom

Find a field

Page 1 of 1 · 32 editable blanks

St. Joseph County Department of Health “To promote health and wellness with compassion and integrity through partnerships, education, protection, and advocacy for all who reside in and visit St. Joseph County.” CONTRACTOR REGISTRATION – WELL Valid until January 31st BUSINESS INFORMATION: BUSINESS NAME: ADDRESS: CITY: STATE: ZIP: COUNTY: E-MAIL (For Department of Health Use ONLY) TELEPHONE #: FAX #: MOBILE #: PAGER #: OWNER INFORMATION: LAST NAME: FIRST: MIDDLE: ADDRESS: CITY: STATE: ZIP: COUNTY: TELEPHONE #: FAX #: MOBILE #: PAGER #: Name of Driller who has passed County Exam: SURETY BOND INFORMATION: ($10,000 Payable to ST. JOSEPH COUNTY DEPARTMENT OF HEALTH) POLICY #: INSURANCE CARRIER and AGENT: ADDRESS: CITY: STATE: ZIP: TELEPHONE #: FAX #: FOR OFFICE USE ONLY! DRILLER / CONTRACTOR ID#: TRANSACTION #: DATE ISSUED: SURETY BOND EXPIRES: DNR WATER WELL DRILLING LICENSES’ (Attach copies - Well Drillers ONLY): ISSUED BY (surety bond made payable to St. Joseph County Department of Health): Waiver on File

Select any highlighted blank to type. A larger copy of the selected question appears here.

Review every page before signing. Professional, agency and notary signature areas stay reserved.Original blank form

Before you begin

Application checklist

Provide the $10,000 surety bond payable to St. Joseph County Department of Health. Well drillers must attach copies of DNR water-well drilling licenses.

Published government fees$200/year well contractor registration, plus any applicable mailing or processing charges.

$200/year well contractor registration, plus any applicable mailing or processing charges.

Current fee schedule lists $3/item mailing convenience fee and card processing fee of 2.55% or $1.55, whichever is greater; electronic checks $2 below $50,000. Confirm actual extras and applicable late charges with the office.

Registration is valid until January 31st. No applicant signature line appears. The DNR license-reference blank is within office-use only and is reserved for staff.

Current Environmental Health contact is envirohd@sjcindiana.gov; older .com addresses remain visible on some original PDFs. Confirm mailing floor before posting a packet.

Official requirements Official source form

Source version: 2026-10-05.regional-1

Your work stays yours

Application answers and files are encrypted in private storage. Authorized service managers can review signing history and documents to process your request.