Applications & Forms

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 do NOT accept credit cards or out-of-state checks.

Please make 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


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

Animal Bites/Rabies
Animal Bite Form

Food Service Operations
Food Service/Food Establishments Application
Food Service/Food Establishment Plan Review
Temporary Food Service Application & Plan Review
Vending Machine Application
Food Service/Food Establishments Mobile Application

Food Service Level 1 Class Registration

Food Service Level 2 Class Registration

Haulers / Septage & Water

Septage Haulers 2017 Registration

Septage Site Renewal Application
Water Haulers Application


Household Sewage Treatment Systems

Registration Application to Install Household Sewage Treatment System

2017 Household Sewage Treatment System Service Provider Registration
Site Inspection Application Form
OK to Use Household Sewage Treatment System Form

Variance Request Form

Procedure for getting a site evalutation


Site Evaluation for Household Sewage Treatment Systems Form

Plumbers Registration

Private Water Systems
Water Sample Request Form
Variance Request
Real_Estate Site Inspection_


Vital Statistics

Birth Certificate Request Form
Death Certificate Request Form
Ohio Department of Health Birth/Death Request Form
Ohio Historical Society Death Certificate Research Request Form