Phone: (937) 548-4196 Fax: (937) 548-9654

APPLICATION FOR RESIDENTIAL DAYCARE INSPECTION

NAME _______________________PHONE #

ADDRESS ________________________________________________________

CITY, STATE, ZIP _________________________________________________

INSPECTION FEE TOTAL: $50 Receipt Number _________

WATER SAMPLE

If the water supply for drinking, washing, bathing and household uses is supplied from a well or other private sources, then it must be tested for Total Coliform Bacteria. This service along with other tests may be completed by the Health Department for the listed cost below.

Total Coliform Bacteria Y N LABORATORY FEE: $13.00

Lead Y N LABORATORY FEE: $14.00

Nitrate/Nitrite Y N LABORATORY FEE: $29.00

Nitrate Y N LABORATORY FEE: $14.00

Nitrite Y N LABORATORY FEE: $12.00

LABORATORY FEES PLUS $35.00 COLLECTION FEE = TOTAL FEE

WATER SAMPLE FEE TOTAL: ________________ RECEIPT #__________

By signing below, the owner/applicant agrees to the inspection of the listed premises as in accordance with the day care inspection sheet. The owner/applicant understands that violations of the Darke County premise sanitation may result in the owner being required to make the appropriate corrections.

By signing below, the homeowner/applicant understands that the health department may inspect the components of the private water system from which the water sample is requested. The owner/applicant also understands that upgrades may be required if deemed appropriate and/or necessary in order to protect public health or safety per OAC 3701-28-19. If for any reason the appointment needs to be cancelled or rescheduled, you must call at least 24 hours prior to the originally scheduled appointment.

APPLICANT SIGNATURE __________________________________________

DATE ____________________________

FOR OFFICE USE ONLY

Location Inspector Date

1^st Sample: __________ __________ ___________ Satisfactory Unsafe

2^nd Sample: __________ __________ ___________ Satisfactory Unsafe

3^rd Sample: __________ __________ ___________ Satisfactory Unsafe

Other Results: ______________________________________________________________________________

Notes:

DATE OF APPOINTMENT: _______________________ TIME: __________________