Hampshire County
Health Department

Hampshire County Health DepartmentHampshire County Health DepartmentHampshire County Health Department
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    • Rabies and Vector Info
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    • Regulations
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  • Preparedness
    • Preparedness Services
  • More
    • Home
    • About
      • Board of Health
      • Calendar of Events
      • Disclaimer
      • Health Department Fees
      • News and Notes
      • Payment Options
      • Privacy Policy
      • Resources
    • Clinical
      • Clinical Services
      • Breast and Cervical
      • Communicable Disease
      • Family Planning
      • Immunizations
      • STD and HIV Testing
      • Tuberculosis
    • Environmental
      • Environmental Services
      • Applications and Forms
      • Clean Air
      • Complaint Form
      • FAQs
      • Food Safety
      • Other Programs
      • Rabies and Vector Info
      • Record Request
      • Regulations
      • Sewage and Water
    • Preparedness
      • Preparedness Services

Hampshire County
Health Department

Hampshire County Health DepartmentHampshire County Health DepartmentHampshire County Health Department
  • Home
  • About
    • Board of Health
    • Calendar of Events
    • Disclaimer
    • Health Department Fees
    • News and Notes
    • Payment Options
    • Privacy Policy
    • Resources
  • Clinical
    • Clinical Services
    • Breast and Cervical
    • Communicable Disease
    • Family Planning
    • Immunizations
    • STD and HIV Testing
    • Tuberculosis
  • Environmental
    • Environmental Services
    • Applications and Forms
    • Clean Air
    • Complaint Form
    • FAQs
    • Food Safety
    • Other Programs
    • Rabies and Vector Info
    • Record Request
    • Regulations
    • Sewage and Water
  • Preparedness
    • Preparedness Services
Applications and Forms

Applications and Forms

The following links are provided for your convenience. Feel free to contact us with any questions you may have. 

Animal Encounters

For Healthcare Provider/Facility
SG-58 Animal Encounter Report Form

Body Piercing/Tattoo Studios

SG-49 Application for Permit to OperateSG-86 - Plan Review Information Report (for new or remodeled studios)SG-88 Piercing Technician Certification ApplicationSG-89 - Client Information and Notification Form (Sample)SG-90 - Hepatitis B Vaccination Declination Statement68-80A - Public Notice: Body Piercing Disclosure Statement

Child Care Centers

SG-49 Application for Permit to OperateSG-99 Child Care Center Plan Review

Food Sanitation

SF-4: Guidelines for Operating a Temporary Food Service Concession (booklet layout)SF-5: Application for Permit to Operate a Food Service EstablishmentSF-5B Application for Permit to Operate a Temporary Food Service EstablishmentSF-7E: Inspection Guide - 2013 Food CodeSF-35: Plan Review Information Report for Food Service Establishments (new or remodeled)SF-35 Addendum: Information PacketForm 1-A: Applicant and Food Employee InterviewForm 1-B: Food Employee Reporting AgreementForm 1-C: Applicant and Food Employee Medical ReferralRetail Food Establishment Emergency Flip Chart

Food Sanitation - Mobile Food Establishments

HB 5017 - Establishes a Statewide Mobile Food Establishment
SF-47 Application for a Statewide Food Establishment PermitSF - 51 Application Out-of State Mobile Food Establishment Permit

General Sanitation

SG-49 Application for Permit to Operate

Manufactured Home Community

SG-49 Application for Permit to OperateForm EG-1 Manufactured Home Community Specifications and Plan Review Summary FormForm EG-2 (Application for a Permit to Construct, Install, Alter, or Extend a Manufactured Home Community)

Recreational Water Facilities

SG-49 Application for Permit to OperateER-32 Recreational Water Facility Weekly ReportSR-153 Recreation Water Facilities Tables

Sewage

SS-182A Application to Install or Modify a Small Sewage Disposal SystemES-57: Affidavit for an Existing Sewage Disposal SystemSS-196 UIC Permit CriteriaSS-197 Change of Certified Installer
For Installers Only:
SS-192: Sewage System Installers Application for Renewal of CertificationSS-192 Installer Certification Renewal Application (ONLINE)
Septic Tank Cleaner Forms:
SS-181 Application For Sewage Tank Cleaning PermitSS-193: Septic Tank Cleaner - Quarterly Log
Subdivision Forms:
ES-76: Subdivision Approval Application Form

Water

SW-252c SpringsSW-252d CisternsSW-252e Installing a Hand PumpSW-252g Pit-less UnitsSW-253: Request for Water AnalysisSW-256 Water Well ApplicationSW-258 Water Well Completion ReportExplanation and Guide to Completing The SW-258SW-259: Water Well Violation ReportSW-260: Water Well Variance Request FormSW-261: Water Well Abandonment ReportSW-262: Water Well Pump Installation ReportExplanation and Guide To Completing The SW-262
Safe Drinking Water Information
How to Disinfect a Private Water WellWater Well Pumping Systems - Private Well OwnersWhat to Do Before Drilling the Well - Private Well OwnersFour Steps to Water Well Safety - Private Well OwnersListing of West Virginia Certified Drinking Water Laboratories

Hampshire County Health Department

16189 Northwestern Turnpike, Augusta, West Virginia 26704, United States

304-496-9640

Copyright © Hampshire County Health Department - All Rights Reserved.

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