Forms

Environmental Health Forms

Food Permit Applications

Note:  Food permits will be emailed, look for an email from HealthSpace Cloud Print in your inbox or spam/junk folder.  Permit holders must print and post their food permit in a location in the food establishment that is visible to the public.

• Application for Permit to Operate a Food Establishment
• (RENEWAL) Application for Permit to Operate a Food Establishment:  Renewal opens online April 1 to May 30.  NOTE:  Added 50% late fee after May 30th, i.e. $150 renewal permit fee + $75 late fee = $225 due.  RENEWAL PERMITS WILL NOT BE ISSUED IF LATE FEES ARE NOT PAID. 
• Application for Food Establishment Construction Plan Review
• Application for Permit to Operate a Temporary Food Establishment (2-14 day event or celebration)
  *Single day events and celebrations are not required to obtain a Temporary Food Permit.  Instead, food safety education materials and guidelines from the Health Department should be obtained and followed.

• Illinois Temporary Food Stand Food Safety Guidelines
• Sanitary Guidelines for Temporary Food Establishments

Cottage Food Operations

Cottage Food Operators are required to register annually with the Clinton County Health Department before selling food products to the public. Cottage Food Operators must follow regulations outlined in the Illinois Food Handling Regulation Enforcement Act.  Currently, there is no fee to register with the Clinton County Health Department.

• Application for Cottage Food Operations Registration
  • Cottage Food Home Self-Certification Checklist
• Food Safety Plan for Acidified and Fermented Foods
• Hazard Analysis Chart
• Sample Hazard Analysis Chart
• Illinois Extension, Cottage Food Information Sheet

Sewage Forms

• Private Sewage Disposal System Information Packet:
  • Instructions for obtaining a Private Sewage Disposal System Construction Permit
  • Private Sewage Disposal System Application
  • EPA, NPDES General Permit Information and Release Form
  • Septic System Do’s and Don’ts
  • Maintenance of Aeration Units
  • List of Licensed Private Sewage Installation Contractors
  • List of Septic Tank Manufacturers and Aeration Unit Dealers
  • List of Licensed Private Sewage Pumpers
  • List of Certified Professional Soil Classifiers

• Variance Request Form
• Application for Approval of an Existing Private Sewage Disposal System
• Private Sewage Installers and Pumpers Registration Form
• Septic Tank Manufacturers and Aeration Unit Dealers Registration Form

Water Supply Forms

• Instructions for Obtaining a Water Well Permit
• Application for Permit to Construct, Modify or Abandon a Water Well
• Application for Permit to Construct, Modify or Seal a Closed Loop Well System
• Application to Seal an Abandoned Water Well by a Property Owner

Complaint Forms

• Nuisance Complaint Form
• Food Complaint Form

Other Forms

Medical Reserve Corp

• MRC Volunteer Application
• SCIMRC:  HIPAA Training
• SCIMRC:  Volunteer Code of Conduct
• SCIMRC:  Liability Form
• SCIMRC:  Oath

Maternal and Child Health Forms

• DHS Self-Employment Record
• Employment and Income Verification form