Public Forms

The following forms are provided for printing and completion. Completed forms may be submitted by fax to 360-379-4487, or returned to:
Jefferson County Public Health
615 Sheridan Street
Port Townsend, WA 98368

Drinking Water

  1. Application For Inspection Of Well Construction, Reconstruction Or Decommissioning (PDF)
  2. Application For Public Water Supply Well Site Inspection. (PDF)
  3. Declaration of Restrictive Covenant (PDF)
  4. Declaration of Well Easement (PDF)
  5. Determination of Adequate Potable Water (PDF)
  6. Two Party Well - Well Operation and Maintenance Agreement (PDF)

Pools & Spas

  1. Pool and Spa Application for Permit (PDF)
  2. Pool and Spa Renewal Form (PDF)

Public Comment/Complaint

  1. Citizen Comment Form (PDF)
  2. Citizen Concern Complaint Form (PDF)

Public Records

Septic

  1. As Built Inspection Report Form - Alternative System (PDF)
  2. Certification of Tank Decommissioning Form (PDF)
  3. Declaration of Easement Form - Different Owners (PDF)
  4. Declaration of Restrictive Covenant Form - Combine Lots (PDF)
  5. Installation Start Notification Form (PDF)
  6. Routing Transmittal Form (PDF)
  7. Septic Permit Application Form (PDF)
  8. Septic Permit Application Instructions (PDF)
  9. Wet Season Evaluation Application (PDF)
The following forms are provided for printing and completion. Completed forms may be submitted by fax to 360-385-9401, or returned to:
Jefferson County Public Health
615 Sheridan Street
Port Townsend, WA 98368

Birth & Death Records

  1. Birth Certificate Application 2021 (PDF)
  2. Death Certificate Application 2021 (PDF)

Information for Health Care Providers


Tobacco

  1. Clean Indoor Air Regulation Variance Request Application Form (PDF)
  2. Violation Report Form (PDF)