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This form is available on the "Information on Failing Residential Water Well" page on the Klamath County website.
Applicants will not be turned away based on income and may be eligible for further assistance through other State grant programs.
Costs Paid for by Others: Recipient may not use any of the Grant to cover costs to be paid for by another State of Oregon agency or any third party.
**A pre-check of your domestic well is a requirement for approval of grant funding. A final inspection is required for release of grant funds.
By signing below you consent Oregon Water Resource Department to inspect your Domestic Well.
Upload a completed IRS W-9 form and include any other documents (maps, receipts, estimates for repair etc.) that will assist the review committee with the processing of your application.
Document upload is REQUIRED before submission.
ALL DOCUMENTS MUST BE COMBINED INTO ONE PDF FILE AND THEN UPLOADED.
I affirm that the information provided above is accurate and true.
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.
This field is not part of the form submission.
* indicates a required field