Public Health Sanitation Forms

NOTICE:  Local Health Departments may require other information or fees in addition to the forms and applications provided here.

A-6: Local Health Departments Environmental Health Staff Contact Information

 

All Forms are in PDF format which requires the Adobe Acrobat Reader (click to download).

 

BOTTLED WATER

Bottlers, please click here for a note on container testing requirements now in place.

• BW-1:  Application for a permit to distribute Bottled Water

• BW-2:  In-State Bottling Requirements

• Bottled Water Design Standards

• Chemical Testing Required for those Renewing Permits to Bottle or distribute Bottled Water in West Virginia

 

DISASTER SANITATION

• SG-80:  Guidelines for Disinfecting Private Water Supplies

• SG-81:  Guidelines for Disinfecting Small Quantities of Water

• SG-82:  Residential Food Safety Guidelines

• SG-83:  Commercial Food Safety Guidelines

• SG-84:  Home Clean-up Guidelines

• Flood Waters and Tetanus - Information You Need To Know

• Health Care Precautions Important During Flood

• Mold In My Home - What Do I Do

 

FOOD SANITATION

• SF-3:  Food Service Establishment Regulations (link to WV Sec of State site for Rule download)
• SF-4:  Guidelines for Operating a Temporary Food Service Concession (booklet layout)

• SF-4:  Guidelines for Operating a Temporary Food Service Concession (portrait layout)

• SF-5:  Application for Permit to Operate a Food Service Establishment
• SF-5:  Application for Permit to Operate a Food Service Establishment (MS Word Fill-In)

• SF-7A:  Food Guide - 1999 Food Code

• SF-7B:  Equipment Guide - 1999 Food Code

• SF-7C:  Management and Personnel Guide - 1999 Food Code

• SF-7D:  Employee Health Guide - 1999 Food Code

• SF-7E:  Inspection Guide - 1999 Food Code
   
• Form 1-A:  Applicant and Food Employee Interview

• Form 1-B:  Food Employee Reporting Agreement

• Form 1-C:  Applicant and Food Employee Medical Referral
   

• SF-35:  Plan Review Information Report for Food Service Establishments (new or remodeled)

• 1999 Food Code Plan Review References - will be updated to 2005 in the near future, but many of the references will be the same

 

• Request for Food Filth Laboratory Analysis - Office of Lab Services

 

• Retail Food Establishment Emergency Flip Chart

 

GENERAL SANITATION

• SG-49:  Application for a Permit to Operate

• SG-49:  Application for a Permit to Operate (PDF Fill-In)

• SG-65:  General Sanitation Regulations (link to WV Sec of State site for Rule download)

 

INDIVIDUAL WATER SUPPLY

Click Here for a listing of, and links to historical well forms, rules & design standards, and policies

• SW-252c, Springs
• SW-252d, Cisterns
• SW-252e, Installing a Hand Pump
• SW-252g, Pitless Units

 

• SW-253:  Request for Water Analysis

 

• SW-256:  Application for a Permit to Construct, Modify or Abandon a Water Well
• SW-256:  Application for a Permit to Construct, Modify or Abandon a Water Well (MS Word Fill-In)
• SW-258:  Water Well Completion Report
• SW-260:  Water Well Variance Request Form
• SW-260:  Water Well Variance Request Form (MS Word Fill-In)
• SW-261:  Water Well Abandonment Report
• SW-262:  Water Well Pump Installation Report

 

• SW-259:  Water Well Violation Report

 

MILK SANITATION

• SM-104:  Grade "A" Pasteurized Milk Regulations (link to WV Sec of State site for Rule download)

 

OTHER PROGRAMS

Body Piercing & Tattoo Studios & Technicians

• SG-49:  Application for a Permit to Operate either type of studio

• SG-49:  Application for a Permit to Operate (PDF Fill-In)

• Tattoo Studio Business Law
  

• SG-78:  Body Piercing Studio Business Rule

• SG-86:  Body Piercing Studio Business Plan Review Information Report

• SG-88:  Body Piercing Technician Application for Certification

• SG-89:  Body Piercing Studio Business Sample Information and Notification Form

• SG-90:  Body Piercing Technician Hepatitis B Vaccination Declination Statement

• 64-80A:  Body Piercing Studio Public Notice

 

Child Care Centers

• SG-49:  Application for a Permit to Operate

• SG-49:  Application for a Permit to Operate (PDF Fill-In)

• SG-98:  Child Care Center Regulations (link to WV Sec of State site for Rule download)

• SG-99:  Plan Review Information Child Care Centers (new or remodeled)

 

Mobile Home Parks

Note:  Please visit the Environmental Engineering web site for more information about Constructing, Installing, Altering or Extending any Mobile Home Park.

• EG-1:  Mobile Home Park Specification and Plan Review Summary Form (link to Environmental Engineering Division)

• EG-2:  Application for a Permit to Construct, Install, Alter, or Extend a Mobile Home Park (link to Environmental Engineering Division)

• EG-3:  Mobile Home Parks Design, Information and Procedural Manual (link to WV Sec of State site for Rule download)

• EG-4:  Sewage System Information and Design Date Sheet (link to Environmental Engineering Division)

• EG-5:  Water System Design Information and Data Sheet (link to Environmental Engineering Division)

• SG-49:  Application for a Permit to Operate

• SG-49:  Application for a Permit to Operate (PDF Fill-In)

• SG-93:  Mobile Home Park Regulations (link to WV Sec of State site for Rule download)

   

  Rabies

• SG-58:  Animal Encounter Report

• SG-58:  Animal Encounter Report (MS Word Fill-In)

• Rabies Pamphlet  (3-fold page layout)

• WV Dog and Cat Rabies Vaccination Law

 

RECREATIONAL WATER FACILITIES

• ER-32:  Recreational Water Facility Weekly Operational Report

• SG-49:  Application for a Permit to Operate

• SG-49:  Application for a Permit to Operate (PDF Fill-In)

• SR-153:  Recreational Water Facilities Tables (Guidelines covering: Closure Events, Required Life Guards, and Water Quality)

• SR-160:  Recreational Water Facilities Regulations (link to WV Sec of State site for Rule download)
   

• Swimming Pool & Spa Construction Application (link to Environmental Engineering Division)

 

SEWAGE

Rules

• ES-52:  Individual and On-Site Sewage Systems Rule

• ES-52:  Individual and On-Site Sewage Systems Rule (booklet layout)

• SS-178:  Sewer Systems, Sewage Treatment Systems, and Sewage Tank Cleaners Regulations

• SS-178:  Sewer Systems, Sewage Treatment Systems, and Sewage Tank Cleaners Regulations (booklet layout)

• SS-180:  Standards for Sewage Tank Cleaning Equipment

• SS-180:  Standards for Sewage Tank Cleaning Equipment (booklet layout)

Forms

• ES-57:  Affidavit for an Existing Sewage Disposal System

• ES-76:  Subdivision Approval Application Form

• ES-76:  Subdivision Approval Application Form (MS Word Fill-In)
   

• SG-55:  Home Loan Evaluation of Well and/or Sewage System Report

• SG-55A:  Home Loan Evaluation Procedures
   

• SS-181:  Application for Sewage Tank Cleaning Permit

• SS-182:  Application for a Permit to Construct, Modify or Abandon a Sewage Disposal System or Water Well

• SS-182A:  Application for a Permit to Install or Modify a Sewage Disposal System

• SS-188:  Application for a Permit to Install or Modify a Sewage Disposal System with Surface Discharge

• SS-188A:  Surface Discharge Site Evaluation Report

• SS-191:  Annual Report For ≤ 600 GPD Point Source Discharging System
   

• Application Package for a Home Aeration Unit with Surface Discharge Permit  (includes SS-188, SS-188A, and necessary DEP forms)
   

• SS-192: Sewage System Installers Application for Renewal of Certification

 

For Local Health Departments and District Environmental Health Offices:

• SG-61:  Sanitarian's Monthly Activity Report (MS Excel)

• SG-61:  Sanitarian's Monthly Activity Report

• SG-79:  Requisition of Environmental Health Forms (MS Word)

• SG-79:  Requisition of Environmental Health Forms