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Please note the Imperial County Public Health Department will be closed to all walk-in services for the public. Department staff will be available to provide assistance by phone to members of the community who have questions related to any of the Department’s essential services.

Phone assistance will be available Monday through Friday from 8:00 am to 12:00 pm and 1:00 pm to 5:00 pm. The office will be closed for lunch from 12:00 pm to 1:00 pm. This shall remain in effect until further notice.

Forms

Animal Adoptions

Adoption & Low-Cost Spay Neuter Agreement              

This form allows Animal Control staff to keep records of the pets being adopted and neuter agreements in accordance with County Code.

Animal Adoption Policy                               

Individuals who choose to adopt an animal from the county shelter must complete and agree to the terms and conditions of this form to begin the process of facilitating an adoption.

Food Facilities

Plan Review Application and Establishment Checklist   

This form is for food facility applicants to provide basic information to the division. It also provides a checklist and guidance information for applicants to be ready for their initial inspection.

Food Facility Health Permit Application

This application is for any food facility. The application includes the location, ownership information, management, and billing informattion. 

Common Restroom Agreement

This form is an agreement for multiple food facilities to share restrooms and most importantly abide by California Health and safety Code Standards.

Mobile Food Facilities

Plan Review Application for Mobile Facility                     

This form is the initial procedure for a Mobile Food Facility.   It will assist the division in evaluating the vehicle.

Mobile Food Facility Health Permit Application

This form identifies the owner, operator, unit information, and operational information to assure there is a responsible party for the vehicle

Commissary Authorization and Permit Application

This form addresses where a food vendor will store the equipment properly and the of the facility allowing the storage of equipment.

Authorization for Use of Restroom Facilities

This form is for facilities to grant permission to Mobile Food Facilities who are operating within 200 feet of their facility, to use the restrooms/hand washing stations.         

Temporary Food Facilities

Application for Community Event Organizer Permit                   

This form indicates what type of event is being proposed. It also shows the contact information of the event’s responsible party.

Application for a Temporary Food Facility Permit

This application shows specific information about the event and lists the proposed consumable items. Staff to ensure proper Health and Safety standards for the public closely review this application.

Cottage Food Operations

Cottage Food Operation Application                                                       

This form includes general information about the Cottage Food Operator and a detailed questionnaire regarding kitchen sanitation requirements, food preparation/packaging/handling, and other Health and Safety standards.

Microenterprise Home Kitchen Operations 

Microenterprise Home Kitchen Operation Standard Operating Procedures                                     

To initiate the review of your application to operate a food buisness within your residential private kitchen, complete and submit this form.

Body Art

Body Art Facility Owner Notice          

This application is the initial form to apply for a body art facility permit. The application consists of general business information, location, and owner information, sanitary services infection prevention control plan, body art practitioners, and the applicant’s certification

Application for Body Art Facility Permit               

This application indicates the practitioner’s information, site of operation, type of body art procedures, days/hours of operation vaccines required and OSHA Bloodborne pathogens training.

Application for Registration of Body Art Practitioner

This application indicates the practitioner’s information, site of operation, type of body art procedures, days/hours of operation vaccines required and OSHA Bloodborne pathogens training.

Body Art Facility Infection Prevention and Control Plan

This form requires the facility operator to fully describe the decontamination and disinfection of ALL equipment used in the facility including the method of properly disposing used tools contaminated with bodily fluids. A sterilization log is attached to this link.       

Health Care Professionals Hepatitis B Declination Statement                                     

A body art facility employee who refuses to take the hepatitis vaccine signs this form.

Application for a Body Art Event Organizer Permit

This form provides the guidelines for such event, general event information requested, waste disposal, a list of body art booths, and a site plan.

Temporary Body Art Facility Application

This form requires general information about the temporary facility, disposal of instruments, booths set up, wastewater disposal and other safety questioner.

Land Use 

Septic System Application Form

This form requests general applicant information, the type of septic system being proposed, the removal or abandonment septic tank if there is an existing septic tank, and the certification (signature) of the installer.

Building Plan Review Application Form                                                                                    

This application requires basic information of the applicant and the proposed project. The proposed project would be analyzed with the septic tank in place.

Permit Application for Septic System

This application is used to apply for a permit to either build, repair, or abandon a septic system.

Wastewater Holding Tank System Application

This application is used to apply for a permit to install an underground sewage-holding tank.  (A sewage-holding tank does not have any leach fields.)      

Information for Obtaining Septic System Permit

This form indicates an applicant to a septic system the requirements needed such as, soil percolation report, site plan, engineered design, and permit fee.

Site Plan Information

This form provides the required information on a site plan, the setbacks information, and a sketch as an example of a site plan.

Imperial County Chambered Leach Field Policy

This policy summarizes the standards and requirements that will be applicable to a leach field utilizing gravel-less chambers in Imperial County. 

Imperial County Existing System Evaluation and Certification Policy     

This form provides the policy and procedures for the evaluation of an existing septic system when the division is unable to locate any record of its approval.  This policy is mostly applicable when it is necessary to supplement information provided for a Building Plan Review Application Form.

POE Pilot Project

Applicants

POE Project Application                                                                                       

The completion of this application is required for those eligible and interested in participating in the POE Pilot Project. 

Homeowner Declaration                   

The completion of this form is required for POE Pilot applicants who do not own the property where the installation of a POE system will occur. Property owners must consent by signing this document prior to any sampling or installation of equipment.

Vendors

Vendor Property Assessment                                                                              

The vendor shall submit this form prior to the installation of a POE system.  This form is used to determine the existing conditions of a property and will be used to determine what POE system components will be necessary for installation.

Initial Source Water Monitoring

The submittal of this form by vendors is required once for the initial samples taken prior to the installation of a POE system.  Laboratory sample results shall be entered into this form and submitted, in conjunction with the lab results, to the division.   

Pressure, Turbidity, Water Usage

This form is used to document the pressure, turbidity and water usage for each POE system.  The form shall be filled out monthly by the vendor and shall be submitted to the division. 

Water Quality Monitoring Data

The submittal of this form by vendors will be required quarterly, and annually. Data on this form will be collected by vendors and tracked by the division throughout the life of the POE Pilot Project.

Pools

Pool Permit                                                                                                 

This application is for any proposed public pool.  The application includes the location, ownership information, management, and billing information.

Pool Plan Review                                                  

This form is utilized when submitting a pool plan review. The form has the current fees, pool facility information, billing, contractor, proposed work, and signature for agreement.

AB 1020 Compliance Form

This compliance form is based on the California Department of Public Health, in accordance with Health and Safety Code Section 116064.2.  The form identifies the type of equipment used for pools for licensed contractors to fill out.

Private Water Systems

Private Potable Water Test Result Submittal Form                                           

This form is to be completed by the person performing the sampling or by the laboratory providing the sampling service and is to be accompanied by the test results for review by the division.

Required Testing to Determine Water Potability

This document demonstrates the required tests needed to determine if the water, whether treated or not, meets potable water standards.  The division verifies all constituents on this document are sampled and meet the standard for potability. 

Plan Review Application Water System

This form shall be submitted when proposing any modifications to the water supply, treatment system, storage tanks, or distribution system. 

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Public Water Systems

Permit Amendment Application Form

This application is used when proposing an amendment to an existing Domestic Water Supply Permit.  The form contains the water system information and the proposed modification or addition to the existing water system.

Domestic Water Supply Application

Use this form to apply for a Domestic Water Supply Permit.  The application consists of the applicant’s information and the proposed water classification (i.e. community, non-transient, transient). 

Bacteriological Sample Siting Plan - Groundwater Systems                                                                                                                         

This form is for ground water systems to denote the locations of where routine and repeat bacteriological samples will be taken.  The form includes the system's information, the laboratory where samples are sent, the sample locations, frequency of sample collection and the person who obtains the samples.

Bacteriological Sample Siting Plan - Surface Water Systems

This form is for surface water systems to denote the locations of where routine and repeat bacteriological samples will be taken.  The form includes the system's information, the laboratory where samples are sent, the sample locations, frequency of sample collection and the person who obtains the samples.

Disinfection Byproducts (DBP) Sampling Plan

This form is the DBP monitoring plan for water systems. The form includes sampling location(s), sampling frequency, and how MCL compliance is calculated. 

DWR - Grout Advisory

This form is to inform well drillers, local enforcing agency staff and others about important sealing material consideration for well construction (annular seals) and destruction in the unsaturated zone in accordance with the California Well Standards.

Emergency Notification Plan

This form is referenced when a water system has an emergency (i.e. confirmed positive bacteriological sample, water line break, loss of pressure, etc).  The form contains the water system name, division staff contact information, and a proposed notification method to the water consumers.

Lead & Copper Reporting Form

This reporting form summarizes lead and copper sampling results.  The form includes the date, location and the results of the testing.  This form must accompany all lead and copper sample results.

Lead & Copper Sampling Plan

This sample-siting plan contains the facility information, sample collection data, map of system and sample locations for lead and copper.

Lead & Copper Worksheet

This form is to assist the tracking of lead and copper sampling results, including sample locations, levels detected and how to calculate the 90th percentile for both lead and copper.

Operation Plan Guidelines

This form pertains to operation plan requirements issued by the State of California Health and Human Services.

State Approved Surface Water Treatment Systems

This form summarizes alternative filtration technologies that have been approved by the State for the treatment of surface water.

TMF Instructions

This document describes how to complete a Technical, Managerial, and Financial (TMF) Assessment form.

TMF Assessment Form

This form shall be filled out by all newly proposed water systems or when a water system change of ownership occurs.  The form includes water system information, person completing the assessment, contact person information, consolidation feasibility, system description, certified operators, source capacity, operations plan, training, ownership, water rights, organization, emergency response plan, policies, budget projection, and budget control.

Septage Haulers

Operating and Permit Requirements for Septage Haulers

This form contains a list of requirements for septage haulers to be permitted to operate within Imperial County.

Application for Septage Hauler Permit

This application must be filled out initially and annually before a septic truck hauler inspection.  It contains the operator information and vehicle information.

Solid Waste

Solid Waste Hauler Registration Form                                                                               

This form must be filled out initially and annually when registering a solid waste hauler with our division. The form contains the business information, owner information, and detailed information about the truck and the capacity of the truck.

Solid Waste Bin Registration Form

This form must be filled out initially and annually when solid waste collection bins are to be used.  The form contains the business information, owner information, and detailed information about the truck and areas of distribution.

County Clean-Up Assistance Program

This informational document provides the steps that are necessary in order to qualify and obtain a clean-up voucher under this county program. 

Solid Waste Clean-Up Voucher Application 

This form shall be completed once the division has approved your property for clean-up assistance in order to obtain the clean-up voucher.