Fillable www.ccchd.com Site Approval Inspection Application Fee $50.00 CLARK (Clark County Board of Commission)

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www.ccchd.com Site Approval Inspection Application Fee $50.00 CLARK (Clark County Board of Commission)

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BROWSE CLARK COUNTY BOARD OF COMMISSION (OH) FORMS

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Revised 12/30/14
CLARK COUNTY COMBINED HEALTH DISTRICT
Division of Environmental Health
Phone: 937-390-5600 Fax: 937-390-5625
www.ccchd.com
Site Approval Inspection Application
Fee $50.00
Receipt #___________
Address of proposed construction
Parcel Number
Owner’s name
Applicant name (if different)
Owner phone number
Applicant phone number
Owner e-mail/fax (approval will be sent here)
Applicant e-mail/fax (approval will be sent here)
Please check, in the left column, agencies who should receive a copy of your approval.
Clark County Community Development Department
Fax: 937-328-2621
- serves townships of Bethel, Green, Harmony,
Mad River, Madison, Moorefield, and Springfield
German Township Zoning
Fax: 937-964-1671
Pike Township Zoning
Fax: 937-964-8328
Pleasant Township Zoning
Fax: 937-828-1427
Other_____________________________________
Fax:_____________
Please answer, below, by circling yes or no.
Is there an on-site sewage system at this address?
YES
NO
Is there a private water system providing drinking water at this address?
YES
NO
Please describe, below, the type of construction being proposed, including how many bedrooms
will be added, if any.
Please attach an overhead “plot plan view” drawing of your property indicating existing
construction, location and dimensions of proposed construction, and complete below . It is
REQUIRED to stake, flag, or paint, with marking paint, the proposed area for construction to
ensure application review in a timely manner. (See examples of drawings on the back of this
form).
Applicant signature (REQUIRED)
Applicant printed name (REQUIRED)
Health District Use Only:
Sanitarian signature
Date:
_____/_____/________
Sanitarian printed name
Approved
Disapproved
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www.ccchd.com Site Approval Inspection Application Fee $50.00 CLARK (Clark County Board of Commission)

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Completed 5 August 2020

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