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Forms for Local Health Districts


The following forms are to be used by the local health district to administer the private water systems program.

Permit Forms

Completion Forms

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

Grout Calculation Spreadsheet

Down-hole Camera (DHC) Requests