Delaware County Health Department
Environmental Food Division
125 N. Mulberry St.
Muncie, IN 47305
(765) 747-7721
DATE SUBMITTED AND PAID:
$
NAME OF ESTABLISHMENT:
LOCATION/ADDRESS:
ANTICIPATED DATE OF OPENING:
(Check one)
New Construction:
Existing/Remodel:
New Ownership/Only:
APPLICATION FOR PLAN REVIEW
Please complete the following, as is applicable to the retail food establishment.
Owner/Corporation Information:
Name:
Contact Person:
Telephone Number:
Mailing Address:
Engineer/Architect Information:
Name:
Contact Person:
Telephone Number:
Mailing Address:
Owner E-Mail:
Establishment Information:
Establishment Name:
Contact Person:
Title:
Establishment Telephone #:
Contact Telephone #:
Establishment Mailing Address, City, State, Zip:
Establishment Street Address, City, State, Zip:
Projected Date for Start of Project:
Projected Date for Completion of Project:
Hours of Operation: Days of Operation: