3303 West Illinois Sp 22
Phone 432.681.7613 Midland, TX 79703
Midland Health Department Environmental Health Permit Application
Page 1 of 7
A permit application must be submitted for each establishment. An incomplete form will not be processed. Failure to secure a
permit before due date of the current year will result in a penalty of 25% per day of the applicable permit fee plus the amount
otherwise due for the permit.
This section of this application concerns the facility owner. The numbered instructions correspond to the numbered fields
(sections) of the form starting on the next page.
1) Check the box th
at best indicates the reason you are applying for a permit
2) Write in today’s date
3) Write one of the following: the name of the sole owner, the business name of the partnership or the names of the
corporation’s officers starting with the President/CEO.
4) DBA is an abbreviation for ‘Doing Business As’. Write the name of the Owner’s business. It is not necessarily the same
name as the regulated facility.
5) Write the address where the primary owner conducts business. This should be the primary owner’s business office
(which could be the permitted facility, a home, a separate office or the corporate mail or local district offices as
appropriate). The Type field is for entering Ave., St., Blvd., etc. The Unit field is for entering the Apt.#, Suite#, etc. If
necessary, write a 2nd address that further specifies the location of the owner. For example, Building A — Fourth Floor.
(It is not necessary to provide detailed directions to the location.)
6) If you want Environmental Health to be able to contact the primary owner at home, write the primary owner’s home
phone number. Also, write the phone number where the primary owner can be reached during normal business hours.
7) Enter the primary owner’s Driver’s License number.
8) Use your company Tax ID.
9) Specify the mailing address of the owner. Also, if this correspondence should be directed to an individual other than the
primary owner, write the name in the “Care of” field.
10) Check the box that best indicates the type of legal ownership.
11) Indicate whether the owner owns just the business or the property as well.