The following forms are to be used by the local health district to administer the private water systems program.
- Permit Application and Site Plan
- Additional Plans Forms as required in section 3701-28-03(E) and (F) of the Administrative Code.
- Required for the construction or alteration of ponds, springs, cisterns, wells drilled in areas of known flowing well conditions, systems serving greater than a three (3) family dwelling, and systems servicing buildings (as defined in section 3781.06 of the Revised Code).
- Administrative Summary Form (electronic fill-in)
- Well Completion Form
- Cistern/Hauled Water Storage Tank Completion Form
- Pond Completion Form
- Spring Completion Form
- Continuous Disinfection Completion Form
Well Log/Sealing Report Search
Transmittal and Report Forms (pdf print only forms)
Water Hauler Registration Reporting Form
Audit Stickers and Water Hauler Stickers
Please submit all requests for additional Audit Stickers and Water Hauler Stickers to BEH@odh.ohio.gov. Place "Private Water Systems Program" In the email subject line and place the number of requested stickers and type in the body of the email.
Contractor Inspection Forms
- Well Driller Contractor Inspection Form
- Pond, Spring, Cistern, Hauled Water Storage Tank Contractor Inspection Form
- Pump Installer Contractor Inspection Form
- This form includes contractor inspections on the installations for backflow prevention devices, casing extensions, continuous disinfection, pitless adapters and units, pressure relief valves, pressure tanks, pump installations, retention/storage tanks, sample faucets, water service pipe distribution, well caps, and yard hydrants.
Grout Calculation Spreadsheet
- Bentonite Grout Calculating Spreadsheet (excel spreadsheet form)
Down-hole Camera (DHC) Requests
- Down-hole Camera Request Form (electronic fill-in)