NAME OF ESTABLISHMENT:
LOCATION/ADDRESS:
PLEASE RETAIN THIS SHEET AND HOLD FOR THE FINAL INSPECTION AND APPROVAL TO OPERATE FROM THE HEALTH DEPARTMENT.
PLEASE HAVE THE FOLLOWING AGENCY REPRESENTATIVE SIGN OFF ON THE FOLLOWING LINE(S) NEXT TO THEIR AGENCY WHEN THEY COMPLETE THEIR INSPECTION AND APPROVAL OF YOUR FACILITY.
I have submitted plans/applications to the authorities listed below: (Check Off)
Zoning:
(765) 747-7740
Sanitary Sewage System:
(765) 747-4896
Fire Department:
(765) 747-4876
Building Commissioner:
(765) 747-4862
Indiana State Fire and or Building Commission: planreview@dhs.in.gov
(317) 232-6422
Private Well – Water: Indiana Department of Environmental Management:
(800) 451-6027
Private Sewage System: Indiana State Department of Health:
(317) 233-7811
Weights and Measure:
(765) 747-7714
ZONING AND PLANNING:
Agency Representative Signature
DATE:
BUILDING COMMISSIONER:
Agency Representative Signature
DATE:
FIRE DEPARTMENT:
Agency Representative Signature
DATE:
SANITARY SEWAGE DISTRICT:
(PRIVATE OR PUBLIC)
Agency Representative Signature
DATE:
WATER (IF PRIVATE WELL):
Agency Representative Signature
DATE:
OTHER:
Specify Agency
Agency Representative Signature
DATE: