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Local Health District Forms


Administrative Summary 

Transmittal and Report Forms (pdf print only forms)

Transmittal and Report forms must be submitted quarterly for permits obtained within the quarter as required in Ohio Revised Code (ORC) 3709.092.  Transmittal and transmittal reports forms must be submitted for all new construction, alterations, and sealings. 


  1. A transmittal form must be submitted although no permits were issued during a quarter.  These may be faxed to the attention of the Private Water Systems Program at (614)466-4556.
  2. Please mark "Replacement" systems as "N" for new construction on the transmittal report forms. 
  3. If a void occurs, please document the audit number and place "Void" in the box under "System Owner".

Water Hauler Registration Reporting Form

ODH now maintains a list of all water haulers registered to haul water for private water systems in Ohio on the website.  Local Health Districts who register water haulers and inspect their vehicles for compliance need to report this information to ODH for inclusion on the list.  This form is provided as a convenience to make it easier to report the necessary information about your registered water haulers. Please return completed forms to:

Audit Stickers and Water Hauler Stickers can be obtained by completing the Literature/Form Request sheet.

Contractor Inspection Forms

                      Backflow prevention devices      Casing extensions      Continuous Disinfection   
    Pitless adapters / Pitless units   Pressure relief valves   Pressure Tanks   
    Pump installations    Retention/Storage tanks     Sample faucets   
    Water service pipe distribution    Well caps    Yard hydrants   

Down-hole Camera (DHC) Requests

Steps that must be completed prior to submitting a down-hole camera request for bacterial problems:

  1. Two positive total coliform or E. coli results from samples collected at the pressure tank or within the jurisdiction of the private water systems program;
  2. Enhanced disinfection and cleaning completed by the private water systems contractor;
  3. Dye test conducted by the local health district sanitarian staff.

Requests for a down-hole camera investigation for wells more than two (2) years old will be evaluated on a case-by-case basis.

Wells that are less than two (2) years old and have sediment problems may have a down-hole camera investigation without having water samples collected and enhanced disinfection conducted. Dye tests are recommended to be conducted in these situations;

Instruct the homeowner:

  • That a working electric outlet must be available with reasonable proximity of the well in order to conduct the down-hole camera investigation;
  • To contact the private water systems contractor about pulling the submersible pump or jet pump lines.
  • The submersible pump or jet pump lines must be pulled from the inside of the well 12-24 hours prior to the down-hole camera investigation;
  • Therefore, water will not be available for possibly 24 hours;
  • Liners, installed inside wells, must be pulled 12-24 hours prior to the down-hole camera investigation;

PWS Contractors

Private water systems contractors may conduct the down-hole camera investigation.

Page reviewed 12/14/2015