Below are forms and/or applications for a variety of programs offered through the Ashtabula County Health Department.  You may print off any of these forms for your convenience.
We Now Accept Credit Cards!!!  Please Call our Office or you may use your credit card at the window.

Please do not send cash in the mail

Bank Checks or Money Orders Accepted

Please make bank checks or money orders payable to the Ashtabula County Health Department.   A return check fee will be charged from the Treasurer’s Office per ORC Section 321.48 for any returned checks.

Ashtabula County Health Department

12 West Jefferson St.

Jefferson,  OH  44047

• PHONE          440-576-6010
• FAX                 440-576-0085 or 440-576-5527

If you would like more detailed information on these programs please select the appropriate link in the Environmental Health section.

ANIMAL BITE FORM

• Animal Bite Form

CONSTRUCTION AND DEMOLITION AND DEBRIS APPLICATION

• Apply Weekdays 8:00 a.m.-10:00 a.m

• C&DD Application

FOOD SERVICE FORMS

• Food Service Plan Review
• Application for Food Service Operation Or Retail Food Service Operation
• Temporary Food License Application
• Vending Machine Operation Application
• Questions and Answers about Mobiles
• Application for Mobile Food License

REGISTRATION FORMS

Apply Weekdays 8:00 a.m.-10:00 a.m.

• Septage Haulers Registration
• Water Haulers Application
• Home Sewage Treatment Service Provider Application
• Application to  Install Home Sewage Treatment System

Apply Weekdays 8:00 a.m.-10:00 a.m.

Home Sewage Treatment Systems 

• Permit Process
• Procedure for Getting a Site Evaluation
• Site Inspection Form
• Home Sewage Treatment System Abandonment Form
• OK to Use Site Inspection Form
• Real Estate Site Inspection Form
• Variance Request Form
• Guidance Packet

PLUMBING

Hours for plumbing department

8:00 a.m. to 9:30 a.m. Weekdays

• Residential Permit Applications
• Commercial Plumbing Plan Review
• Plumbers Registration

PRIVATE WATER SYSTEM FORMS

• Chlorination Procedure
• Water Sample Form 
• Variance Request Form
• Real Estate Site Inspection Form
• Well Permit Application

Online Viewing of Private Water Systems Well Logs

Click the link below to view water well logs

*** OHIO DEPARTMENT OF NATURAL RESOURCES WATER WELL LOG ***

VITAL STATISTICS

The hours of operation for ALL Vital Statistics requests

*8:00 a.m. to 4:00 p.m.  Weekdays unless other wise noted*

• Records Request Information
• Vital Statistics Form Birth
• Vital Statistics Form Death
• Ohio Historical Society Death Certificate Research Request Form