Forms & Applications

All applications and forms are to be turned in to your local health department. Contact your local health department with questions regarding these applications and forms. The Chickahominy Health District accepts cash, checks and VISA for fees associated with applications.

Food Service Applications, Forms, & Regulations

Name: Description:
Food Establishment Application Application for a Virginia Department of Health Food Establishment Permit
Foodservice Plan Review Plans to review for approval before food establishment permit
FDA Food Establishment Plan Review Guide Food and Drug Administration’s guide to assist food establishments in foodservice plan reviews.
Temporary Food Establishment Application

Event Coordinator Application

*These forms can be emailed to Chickahominy.EHSS@vdh.virginia.gov if $40 fee has been previously paid within the past calendar year.

Application for a temporary food establishment. Temporary event applications must be submitted 10 business days prior to an event
Virginia Food Regulations
FDA Federal Food Code Document Food and Drug Administration’s guide to ensure food and public health safety from food establishments
Chickahominy Health District Complaint Information Form
*This form can be emailed to Chickahominy.EHSS@vdh.virginia.gov
Complaint information form for water, sewage, restaurants, methamphetamine, wells, foodborne illnesses, etc.
Mobile Food Unit Application

Mobile Unit Plan Review Document

Application for a Department of Health Mobile Food Unit Permit

 

Septic System Repair Malfunction Assessment and Instructions

Name: Description:
Chickahominy Health District Septic System Repair History Questionnaire and Instructions
*This form can be emailed to Chickahominy.EHSS@vdh.virginia.gov
Septic system repair instructions and repair history questionnaire
Malfunction Assessment
Septic System Repair Instructions
Chickahominy Health District Request for Onsite Information Application to request information on wells, septic systems, or drainfields
Chickahominy Health District Complaint Information Form
*This form can be emailed to Chickahominy.EHSS@vdh.virginia.gov
Complaint information form for water, sewage, restaurants, methamphetamine, wells, foodborne illnesses, etc.
Chickahominy Freedom of Information Request Form Form to request documents or other information under the Freedom of Information Act
VDH Septic System & Well Construction Permit Application Application for construction permit for wells or septic systems
Application-Onsite

 

Other Applications, Forms, & Regulations

Name: Description:
Hotel Application Application for a Department of Health Tourist Establishment/Campground/Summer Camp Permit
Summer Camp Application Application for a Department of Health Summer Camp Permit
Campground Application

Application for a Campground Plan Review

Applications for a Department of Health Campground Permit and Plan Review
Tourist Establishment Regulation
Migrant Labor Camp Application Application for a Migrant Labor Camp Permit

 

Epidemiology Forms

Name: Description:
EPI 1 Form PDF Form to report disease cases to your local health department.