Environmental Health Forms and Applications
We've Moved!
The Environmental Health Division is now located at 1221 W. State St., Suite B, in El Centro, CA, 92243. icphd.org/ehd-new-address
If you have any questions, please call us at 442-265-1888.
Translations
Please note all documents listed here are in English; Spanish translations are coming soon!
How to add an Electronic Signature
Electronic-Signature
Some items listed require a signature through Adobe Acrobat. Follow the steps below for the various ways an electronic signature can be applied. E-signatures are not allowed on Approved Kitchen Letter and the Commissary Agreement which are found in the Temporary Food Facility Application Packet.
Downloading the Installer:
Download Adobe Acrobat Reader (if you don't have the software)
Once on the Adobe Reader download page, you'll find a "Download" button.
Select your operating system (Windows or macOS).
Click the "Download" button to initiate the download.
You may see the downloaded file in your browser's download bar (e.g., lower-left corner in Chrome).
Running the Installer
Locate the downloaded installer file on your computer.
Windows: Double-click the downloaded EXE file to run the installer.
macOS: Double-click the downloaded DMG file to open the installer.
If prompted, allow the installer to make changes to your computer (User Account Control in Windows
Installation Process
Follow the on-screen instructions provided by the installer.
This typically involves:
Accepting the End User License Agreement.
Choosing an installation location.
Waiting for the installation to complete.
Launching and Signing In:
Once installation is complete, click "Launch Acrobat".
You may be prompted to sign in with your Adobe ID or social account (Facebook or Google).
Signing in provides access to Adobe Document Cloud service
Must create or have an Adobe Acrobat Reader account to create a Digital ID
- A pop box will appear asking if you would like to configure a Digital ID.
- Select Configure Digital ID
- Select Create a new Digital ID
- Save to Windows Certificate Store
- Select the Digital ID you created
- Select a Document to fill
- In top left corner select the pen tool drop down arrow
- Select the color Black
- Sign your name in designated signature box
- Save document to a location on your computer
Questions Regarding Fees
Refer to the Fees page for more details
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Icon Legend
Each form or application may include fees or general guidelines. Please refer to the icon legend to understand the purpose of each form and any associated details
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Animal Care & Control
Potential Pet Owners
Adoption & Low-Cost Spay Neuter Agreement 📝💵 |
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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 📝💵 |
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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. |
Animal Care and Control Fees
| Adoption | $20.00 |
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| Spay | $65.00 |
| Neuter | $35.00 |
| Rabies Vaccine | $6.00 |
Body Art
Tattoo Parlors, Permanent Makeup
Body Art Facility Permit Application 📝 💵 |
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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. Download Body Art Facility Permit Application PDF Fee: $267.00 |
Body Art Practioner Application📝💵 |
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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. Download Body Art Practioner Application PDF Fee: $150.00 |
Body Art Facility Infection Prevention and Control Plan Guideline 📖 |
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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. Download Body Art Facility Infection Prevention and Control Plan Guideline PDF |
Voluntary Declination of Hepatitis B Vaccination 📝 |
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A body art facility employee who refuses to take the hepatitis vaccine signs this form. Download Voluntary Declination of Hepatitis B Vaccination PDF |
Body Art Plan Check Guide 📖 |
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This guideline provides information about body art facilities. It contains requirements for equipping a body art facility. |
Temporary Body Art Event Organizer Permit Application 💵📖📝 |
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This guideline includes the form for such event, general event information requested, waste disposal, a list of body art booths, and a site plan. Download Temporary Body Art Event Organizer Permit Application PDF Fee: $407.00 |
Temporary Body Art Booth Application 📝💵 |
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This application form requires general information about the temporary facility, disposal of instruments, booths set up, wastewater disposal and other safety questions. Download Temporary Body Art Booth Application PDF Fee: $237.00 |
Other Body Art Fees
| Tattoo and Body Art Event Late Submittal Expedited Processing Fee (organizer and/or per booth submittal) | $75.00 plus Permit Fee |
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| Re-inspection | $163.00 |
| Enforcement Activity | $163.00/hr |
Food Facilities
Restaurants, Taco Shops, etc.,
Plan Review Guide For Food Facilities📝📖 |
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This guideline and 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📝💵 |
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This application form is for any food facility. The application includes the location, ownership information, management, and billing information. Download Food Facility Health Permit Application PDF Fees: Please navigate to the Food Facility section on Environmental Health Fees webpage |
Common Restroom Agreement for Establishments with Multiple Food Facilities 📝 |
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This form is an agreement for multiple food facilities to share restrooms and most importantly abide by California Health and Safety Code Standards. Download Common Restroom Agreement for Establishments with Multiple Food Facilities PDF |
Retail Food Plan Review Application📝💵 |
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This form is the initial procedure for a Food Facility. It will assist the division in evaluating the facility. Download Retail Food Plan Review Application PDF Fees: Please navigate to the Food Facility section on Environmental Health Fees webpage |
Approved Floor Coverings📖 |
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This guideline provides diagrams and information for properly installing flooring in a food facility. |
Request for Consultation 📝💵 |
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This form is used to obtain a health inspection prior to entering a contract for lease/rent a facility to obtain health inspector’s guidance as to what consumable items may be prepared and sold and/or to determine to what extent modifications must be made (e.g. sinks, approved flooring, water heater). Download Request for Consultation PDF Fee: $163.00 (1 hour) Fees: Please navigate to the Food Facility section on Environmental Health Fees webpage |
Request for a Re-Score or Re-Inspection 📝💵 |
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Use this form to apply for a re-inspection or a re-score inspection. This form is also used to apply for an inspection to re-open a food facility after a failed inspection. Download Request for Re-Score or Re-Inspection PDF Re-score Inspection Fee: $157.00 Re-inspection Fee: $163.00 |
Food Inspection and Grading Guide 📖 |
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Use this guide to understand the food inspection and the grading system. |
Mobile Food Facilities
Taco Trucks, Coffee Carts etc.,
Mobile Food Facility Health Permit Application 📝💵 |
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This form identifies the owner, operator, unit information, and operational information to assure there is a responsible party for the vehicle. Download Mobile Food Facility Health Permit Application PDF Fees: Please navigate to the Food Facility section on Environmental Health Fees webpage |
Commissary Authorization and Permit Application 📝💵 |
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This permit application addresses where a food vendor will prepare and store food for the mobile. Download Commissary Authorization and Permit Application PDF Fee: $233.00 |
Authorization for Use of Restroom Facilities 📝 |
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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. |
Request for Consultation 📝💵 |
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This form is used to obtain an evaluation prior to entering a contract to lease/rent a facility. The evaluation will aid in determining what modification may be needed for the facility to obtain a permit to operate. Download Request for Consultation PDF Fees: Please navigate to the Food Facility section on Environmental Health Fees webpage |
Mobile Food Facility Construction Guide 📖 |
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This guide contains important equipment requirements for a mobile food facility. |
Temporary Food Facilities
Community events, examples: (IV Midwinter Fair and Fiesta, Cattle Call, In the Park after Dark, Holtville Carrot Festival etc.)
Community Event Organizers 📝💵 |
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This form indicates what type of event is being proposed. It also shows the contact information of the event’s responsible party. Download Community Event Organizers PDF Fees: Please navigate to the Food Facility section on Environmental Health Fees webpage |
Application for Temporary Food Facility Permit 📝💵 |
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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. E-signatures are not allowed on Approved Kitchen Letter and the Commissary Agreement which are found in the Temporary Food Facility Application Packet. Download Application for Temporary Food Facility Permit PDF Fees: Please navigate to the Food Facility section on Environmental Health Fees webpage |
Cottage Food Operations (CFO)
Home food preparation operators for Non-potentially Hazardous (NPH) Foods.
Application for Cottage Food Operation Registration/Health Permit 📝💵 |
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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. Download Application for Cottage Food Operation Registration/Health Permit PDF Class A Fee: $233.00 Class B Fee: $320.00 |
Microenterprise Home Kitchen Operations (MEHKO)
Home food preparation operators for Potentially Hazardous (PH) Foods for dine in, take out or pick-up
MEHKO Standard Operating Procedures📝 |
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Please complete this form to start the review of how you will operate a food business from your home kitchen. |
Food Facility Health Permit Application📝💵 |
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This application is for any food facility. The application includes the location, ownership information, management, and billing information. Download Food Facility Health Permit Application Fee: $370.00 |
MEHKO Guidelines 📖 |
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These guidelines help people who want to cook and sell food from their own home. They explain what you need to do to get permission and keep your kitchen safe, following California’s food safety rules. |
MEHKO FAQ📖 |
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A MEHKO is a mini restaurant in a home kitchen that is operated by the resident. Please find some of the most frequently asked questions (FAQs) about MEHKO’s below. |
MEHKO Quick Facts📖 |
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A Microenterprise Home Kitchen Operation (MEHKO) is a type of food facility, which has been permitted by Imperial County Environmental Health to be operated in a private home. Learn quick facts about the MEHKO requirements, limitations, and how to get started. (Read if this is your first time) |
Land Use
Facility/Property Owner
Permit Application for Septic System📝💵 |
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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. Download Permit Application for Septic System PDF Fees: Please navigate to the Liquid Waste/Sewage System section on Environmental Health Fees webpage |
Plan Review Request Application📝💵 |
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This application requires basic information of the applicant and the proposed project. The proposed project would be analyzed with the septic tank in place. Download Plan Review Request Application PDF Fees: Please navigate to the Plan Review section on Environmental Health Fees webpage |
Permit Application for Wastewater Holding Tank System📝💵 |
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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.) Download Permit Application for Wastewater Holding Tank System PDF Fees: Please navigate to the Liquid Waste/Sewage Systems section on Environmental Health Fees webpage |
Information Packet for a new Septic System 💵📖📝 |
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This document is an information packet containing documents used in the process of obtaining a new septic permit. This form can be used for new septic systems, replacement, or alterations. Download Information Packet for a new Septic System PDF Fees: Please navigate to the Liquid Waste/Sewage Systems section on Environmental Health Fees webpage |
Chambered Leach Fields Policy📖 |
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This policy summarizes the standards and requirements that will be applicable to a leach field utilizing gravel-less chambers in Imperial County. |
Existing System Evaluation and Certification📖 |
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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 Plan Review Application Form. |
Soil Evaluation, Testing, and Reporting Policy📖 |
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This policy summarizes the standards and requirements that are applicable to evaluating a site for the installation of a new or replacement OWTS (i.e. septic system) |
Robert A. Taft Method of Soil Percolation Testing Document📖 |
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The percolation test shall be conducted utilizing the hole preparation, soil saturation and rate measurement procedures outlined in the U.S. Department of HEW, Public Health Service Manual of Septic Tank Practice (Robert A. Taft Sanitary Engineering Center Procedure) Download Robert A. Taft Method of Soil Percolation Testing Document PDF |
Imperial County Local Agency Management Program Document📖 |
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This Local Agency Management Program (LAMP) is a custom plan to manage septic systems in Imperial County. A state law (AB 885) and new water quality rules approved in 2012 allow the County to set local standards that fit our area, as long as they protect water quality just as well as state rules. Download Imperial County Local Agency Management Program Document PDF |
Imperial County Onsite Wastewater Treatment System Ordinance📖 |
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A new ordinance that updates Imperial County's rules about septic systems for land development projects. Download Imperial County Onsite Wastewater Treatment System Ordinance PDF |
Point of Entry (POE) Pilot Project
General Public
Applicants
Point of Entry Water Program Application 📝 |
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The completion of this application is required for those eligible and interested in participating in the POE Pilot Project. Access Point of Entry Water Program Application Microsoft Form |
Homeowner Declaration 📝 |
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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
Initial Source Water Monitoring 📝 |
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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. |
Water Quality Monitoring Data 📝 |
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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
Public Pools such as hotels, community pools & apartment complex
Public Pool Permit Application📝💵 |
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This application is for any proposed public pool. The application includes the location, ownership information, management, and billing information. Download Public Pool Permit Application PDF Fees: Please navigate to the Public Pools and Spas section on Environmental Health Fees webpage |
Public Pool Plan Review Application📝💵 |
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This form is used to submit a pool plan for review. The form has the current fee, facility information, billing contractor, proposed work and signature for agreement. Download Public Pool Plan Review Application PDF Fees: Please navigate to the Public Pools and Spas section on Environmental Health Fees webpage |
Public Pool Plan Review Guide 📖 |
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This guide provides information for constructing a public pool. It includes guidance for equipment and construction diagrams. |
Guidelines for Use of Pool Covers on Public Swimming Pools, Spas and Wading Pools 📖 |
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This document describes the various types of pool covers which are currently available and offers safety standards for their use on public pools. For the purpose of these guidelines, the term pool refers to swimming pools, spas, and wading pools. Download Guidelines for Use of Pool Covers on Public Swimming Pools, Spas and Wading Pools PDF |
Public Pool Informational Guideline 📖 |
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A guide provided to educate public pool operators about maintenance practices and safety requirements. |
Fecal Incident Response Recommendations for Aquatic Staff 📖 |
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What do you do when you find poop in the water? Check for existing guidelines from your local or state regulatory agency before use. CDC recommendations do not replace existing state or local regulations or guidelines. Download Fecal Incident Response Recommendations for Aquatic Staff PDF |
Private Water Systems
General Public
Potable Water Test Result Submittal Sheet 📝💵 |
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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. Download Potable Water Test Result Submittal Sheet PDF Fees: Please navigate to the Plan Review section on Environmental Health Fees webpage |
Required Testing to Determine Water Potability 📖 |
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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. |
Public Water Systems
General Public, Property Owners
Application for Domestic Water Supply Permit 📝💵 |
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Use this application 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). Download Application for Domestic Water Supply Permit PDF Fees: Please navigate to the Public Water Systems section on Environmental Health Fees webpage |
Application for Domestic Water Supply Permit Amendment 📝💵 |
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This application is used when proposing an amendment to an existing Domestic Water Supply Permit. The application contains the water system information and the proposed modification or addition to the existing water system. Download Application for Domestic Water Supply Permit Amendment PDF Fees: Please navigate to the Public Water Systems section on Environmental Health Fees webpage |
Operations Plan Requirements📖 |
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This form pertains to operation plan requirements issued by the State of California Health and Human Services. |
State Approved Surface Water Treatment Systems📖 |
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This form summarizes alternative filtration technologies that have been approved by the State for the treatment of surface water. |
Instructions for Completing the Technical, Managerial, and Financial (TMF) Assessment Form📖 |
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This document describes how to complete a Technical, Managerial, and Financial (TMF) Assessment form. |
TMF Assessment Form📖 |
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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. |
Stage II Disinfection Byproduct (DBP) Rule Monitoring Plan Form📝 |
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This form is the DBP monitoring plan for water systems. The form includes sampling location(s), sampling frequency, and how MCL compliance is calculated. Download Stage II Disinfection Byproduct (DBP) Rule Monitoring Plan Form PDF |
Bacteriological Sample Siting Plan - Surface Water Systems📝 |
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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. Download Bacteriological Sample Siting Plan - Surface Water Systems PDF |
Bacteriological Sample Siting Plan - Groundwater Systems with Continuous Disinfection📝 |
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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. Download Bacteriological Sample Siting Plan - Groundwater Systems with Continuous Disinfection PDF |
Water Quality Emergency Notification Plan📝 |
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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 and Copper Tap Sample Results Reporting Form📝 |
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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. Download Lead and Copper Tap Sample Results Reporting Form PDF |
Lead and Copper Sampling Siting Form📝 |
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This sample-siting plan contains the facility information, sample collection data, map of system and sample locations for lead and copper. |
Lead and Copper Results Worksheet📝 |
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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. |
Water System Facility Information 📝💵 |
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This form must be completed when filing any type of water system permit. This form allows Imperial County to maintain its databases for reaching out to small water systems with important information (e.g., invoicing, notices, etc.). Download Water System Facility Information PDF Fees: Please navigate to the Public Water Systems section on Environmental Health Fees webpage |
Plan Review Application Water System📝💵 |
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This application shall be submitted when proposing any modifications to the water supply, treatment system, storage tanks, or distribution system. Download Plan Review Application Water System PDF Fees: Please navigate to the Public Water Systems section on Environmental Health Fees webpage |
Septage Haulers
General Public, Property Owners
Operating and Permit Requirements for Septage Haulers 📖 |
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This form contains a list of requirements for septage haulers to be permitted to operate within Imperial County. Download Operating and Permit Requirements for Septage Haulers PDF |
Application for Septage Hauler Permit 📝💵 |
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This application must be filled out initially and annually before a septic truck hauler inspection. It contains the operator information and vehicle information. Download Application for Septage Hauler Permit PDF Fees: Please navigate to the Liquid Waste/Sewage Systems section on Environmental Health Fees webpage |
Business Modification Form 📝 |
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This form is used to properly document the inactivation of a permitted vehicle that will no longer operate in Imperial County. |
Solid Waste
General Public, Facility Operators
Solid Waste Hauler Registration Form 📝💵 |
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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. Download Solid Waste Hauler Registration Form PDF Fee: $346.00 first registered vehicle $62.00 for additional vehicles |
Solid Waste Bin Registration Form📝💵 |
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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. Download Solid Waste Bin Registration Form PDF Fee: $382.00 |
County Clean-Up Assistance Program (CCAP)📖 |
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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 Cleanup Voucher Application📝 |
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This application shall be completed once the division has approved your property for clean-up assistance in order to obtain the clean-up voucher. |