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Applications / Forms - Environmental Health Division

Notice: Before using any of these forms, please call the Environmental Health Office at (517) 788-4433 to ensure you are using the correct form.
Failure to call ahead may result in your having to resubmit forms.

 

Click on the individual form or pamphlet below which you are interested in opening for printing and or submitting to the Environmental Health Office. Some of the forms are linked with state sites.

 

Norovirus Information

Norovirus Contamination Cleanup Adobe Reader is Required to View this Document – Guidelines for environmental cleanup of suspected Norovirus contamination.
Norovirus - Michigan Dept. of Community Health – Links to the Michigan Department of Community Health Norovirus information site.
Norovirus Centers for Disease Control – Links to the National Center for Infectious Diseases.


Food Establishment Links

Basics of Food Safety Adobe Reader is Required to View this Document  – Flyer for free class offered by the JCHD Env. Health Division.
Cooling Log Adobe Reader is Required to View this Document – Form for documenting food storage temperatures in first 6 hours.
Food Plan Review –-Links to MDA site and includes application, worksheet and manual.
Food Service Application Adobe Reader is Required to View this Document - Application for Food Service License (type and print format)
Food Service License – Links you to the Mich. Dept. of Agriculture (MDA) site.
Guidance for Fund Raising Events Adobe Reader is Required to View this Document - Guide to rules regarding preparation of food for fund raising events.
Standard Operating Procedure (SOP) Examples – Links to National Food Service Management Instituate (NFSMI) site.
STFU Intent to Serve - Form for licensed Special Transitory Food Unit (STFU) to notify us of their intent to serve within Jackson County.
Types of Food Service Licenses – Links to MDA site. Fee varies by county.

Temp Food Booklet     - Food Safety and Licensing Guide
Temporary Food Service LicenseAdobe Reader is Required to View this Document – Links to the MDCH webpage license application.
MDA – Food Establishment Plan Review Manual Adobe Reader is Required to View this Document – Links to MDA Site.
ServSafe Information  – ServSafe Class registration     Click here  Adobe Reader is Required to View this Document for a pamphlet.
Updated Food Law – Food Law changes effective 10/01/2012  


Soil Erosion and Sediment Control

SmokeFree Law Information

Smoke Free Law Information

Public Act 188 Complaint Form Adobe Reader is Required to View this Document – Use for reporting a site noncompliant with smoke-free law - Complaint form must have a name / signature and phone number. 


Well & Septic Forms / Applications

Please note the following forms have now been combined into one fillable form for ease and convenience: Raw Land Application, Site Evaluation Application and Well or Sewage System Permit Application.  They are still listed separately below for your convenience.
Application Addendum Adobe Reader is Required to View this Document – Must be completed by applicant for an existing or replacement sewage system permit.
Commercial Septic Worksheet Adobe Reader is Required to View this Document – Must be completed when applying for a commercial well or sewage system permit.
Raw Land Application  Adobe Reader is Required to View this Document – To be used only when determining if a property is suitable for an onsite sewage disposal system. It does not replace the requirement for a site evaluation prior to permit issuance. Typically used during real estate transactions.

Sanitary Code - JCHD Guidelines for Interpreting the Sanitary Code
Site Evaluation ApplicationAdobe Reader is Required to View this Document – Must be completed prior to issuance of permits. The only exception may be subdivision lots. Contact the office if you have questions.
Site Evaluation Grid (Plot Plan) Adobe Reader is Required to View this Document – This is the form for submitting a detailed plot plan. This grid must be submitted with the site evaluation application.
Site Evaluation Grid Sample  Adobe Reader is Required to View this Document – This is an example of how the grid should be completed.
Well Out of Water Declaration Adobe Reader is Required to View this Document- Must be completed and signed by the owner.
Well Plugging Agreement Adobe Reader is Required to View this Document – Must be completed with application when replacing an existing well.
Well or Sewage System Permit Application Adobe Reader is Required to View this Document – Application required for well or sewage system permits.


Water

Other

Nuisance Complaint Adobe Reader is Required to View this Document – Complaint form must have a name / signature and phone number

 
This page originated on June 26, 2015 and was last modified on January 15, 2016

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