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(Over) INSTRUCTIONS FOR COMPLETING THE COMMERCIAL ON-SITE SEWAGE SYSTEM PRE-APPLICATION Part of State Form 56275 (R3 / 2-23) Section 1. Project Information – Provide the name of your proposed project or business. Section 2. Project Location – Provide the location information of the proposed project: 1. If the proposed location does not have an address yet, provide location information (e.g. across the road from 555 CR 200 North; or northeast corner of SR 3 and CR 200 North intersection) that can be used to locate the property on web maps. Include city/town name and the county in which the project is located. Section 3. Applicant / Agent Contact Information – Provide the information of applicant or agent who will be the main contact (e.g. project manager) of the project: 1. Include a postal address, city, state, ZIP code, telephone number and an email address. Section 4. General Project Details – Complete the general project details section: 1. Provide the general project details regarding the business / facility hours (e.g. M – F, 8:00 AM to 5 PM). 2. Include the total number of employees for full time, part time, and seasonal for each shift. If you are planning on expanding the business in the near future, include the additional employees in your numbers. 3. If the facilities will have shower facilities on-site, please provide frequency of the shower use. If employees are required to shower before and/or after entering and/or exiting the facility (e.g. 2 times per day at the facility), note this in the applicable box. Check No if none or if only for emergency use. 4. If the facilities will include a washing machine(s), provide the maximum number of loads of laundry that would be done in one day. 5. Please indicate if there will be a residential sized washing machine(s) or if there will be a commercial/industrial sized washing machines. 6. For commercial facilities that include living quarters, bedrooms, or a residence to be included in the proposed on-site sewage system assessment, provide the number of bedroom units. An example would be the following: The apartment building will have five 1-bedroom apartments, ten 2-bedroom apartments, and four 3-bedroom apartments. 7. Provide the estimated peak amount of customers and the average length of stay (only if they have access to the facility’s restrooms). 8. Provide a brief business narrative describing your proposed project / facility below. If you require additional space to complete the narrative, attach additional pages as needed. 9. Include a typed name or signature certifying the information provided is true, complete, and accurate to the best of your knowledge. 10. Please see the following brief business narrative examples. The Lakeside Restaurant will have seating capacity of 22 patrons. We will staff up to 4 wait staff, 1 hostess, 3 chefs, 1 bartender, and 1 dishwasher. The kitchen equipment will include an eight top burner stove and convection oven. ---PAGE BREAK--- INSTRUCTIONS FOR COMPLETING THE COMMERCIAL ON-SITE SEWAGE SYSTEM PRE-APPLICATION (continued) Part of State Form 56275 (R3 / 2-23) Office Solutions is a family based consulting firm for stream lining your business operations to help make your office run like a well-oiled machine. Our staff will consist of 8 sales people, 4 executives/managers, and 1 receptionist. The breakroom will consist of a refrigerator and microwave oven. There will be no showers on-site, no full meals will be prepared for the staff, and a single men’s and women’s restrooms. Customer visits will be rare and infrequent. Maximum of 1 on-site visit per month for conferences and/or meetings. If your proposed business is a wedding venue / event center, church or religious facility, restaurant / food service provider, kennel, veterinarian clinic, or campground, complete applicable sections on page 2 of the pre-application form. Section 5. For wedding venues / event centers: 1. Provide the number seats available for patrons. Do not put the fire / safety occupancy level. ISDH sizes wedding and event centers based on the maximum number of seats provided; 2. Indicate if the proposed facility will have an on-site kitchen where full meals will prepared, cooked, and served on-site. If so, provide a full menu of the food to be cooked and the method of cooking (i.e. baked, grilled, and/or fried) of each food. 3. Indicate if you will be utilizing an outside catering service where food will be prepared off-site. 4. If so, indicate if the outside catering service will be taking the used dishes off-site to be washed or if dishes will be washed on-site. Section 6. Churches and Religious Facilities: 1. Provide the number of sanctuary / worship area seats (not the average attendance); 2. If there are wooden pews, provide the total lineal feet of pew space (e.g. 300 feet); 3. Indicate if the proposed facility will have an on-site kitchen where full meals will be prepared, cooked and served on-site. If so, provide a full menu of the food to be cooked and the method of cooking (i.e. baked, grilled, and/or fried) of each food and how frequently this will occur and how many people could attend. 4. Indicate if food will be prepared off-site and brought in (e.g. potluck / carry-in / pitch-in). If so, will glasses, dishes and flatware be cleaned on or off-site? 5. Will there be any large gatherings or events? 6. If so, provide a projected number of events, attendees per event, and if food will be served. 7. Is there a day care facility operated outside of normal worship hours? 8. If so, provide the total number of children and employees. 9. Is there an accredited school (not Sunday school) on-site? 10. If yes, provide the total number of elementary students, secondary students, and educators / staff. Section 7. Restaurant / Food Service Provider: 1. Indicate the type of restaurant (check the applicable box). 2. Are meals prepared from scratch or pre-made ready to cook? 3. Will glasses, dishes and flatware be washed on-site? Section 8. Kennel and Veterinarian Clinics: 1. Provide applicable numbers for each of the categories found in this section. If your facility will not have any of that particular category, enter 0. Section 9. Campgrounds: 1. Provide applicable numbers for each of the categories found in this section. If your facility will not have any of that particular category, enter 0. ---PAGE BREAK--- Page 1 of 2 COMMERCIAL ON-SITE SEWAGE SYSTEM PRE-APPLICATION State Form 56275 (R3 / 2-23) INDIANA DEPARTMENT OF HEALTH ENVIRONMENTAL PUBLIC HEALTH FOR INTERNAL USE ONLY Project number INSTRUCTIONS: 1. All commercial applicants must complete the questions below and submit with the soil report. 2. Provide accurate information and factor in long term use of the site. 3. E-mail questions to [EMAIL REDACTED] or call (317) 233-7811. 4. Completed applications may be submitted via e-mail at [EMAIL REDACTED]; via fax at (317) 233-7047; or via mail at: Environmental Public Health Division, Indiana Department of Health 2 North Meridian Street, 7-D, Indianapolis, IN 46204 1. PROJECT INFORMATION Name of project / business 2. PROJECT LOCATION (If no address exists, please use an approximate location - e.g. 1/2 miles west of 123 W. Hwy 20 or the nearest intersection.) Project / business location Project / business city County location of project / business 3. APPLICANT / AGENT CONTACT INFORMATION Name of applicant / agent representative Postal address of applicant / agent (number and street, city, state, and ZIP code) E-mail address of applicant / agent Telephone number of applicant / agent ( ) Extension Fax number of applicant / agent ( ) 4. GENERAL PROJECT DETAILS Specify the days and hours of operation for the facility. Number of employees at peak staffing: (Include any anticipated future growth.) First Shift: Full time Part Time Seasonal Second Shift: Full time Part Time Seasonal Third Shift: Full time Part Time Seasonal Are there shower facilities on-site? (Check no if none or if only for emergency use.) Yes No Frequency of shower use (Note if facility requires showers before and after shifts.) Are there washing machines on-site? Yes No If yes, type(s) of machine(s) Residential washing machine Commercial / industrial washing machine Number of laundry loads per day For commercial facilities with bedrooms, list number of bedrooms (e.g. five 1-bedroom, ten (10) 2-bedroom and four 3-bedroom units) If customers have access to a restroom while at the business, provide the estimated peak customers per day and average length of stay. Provide a brief business narrative describing your proposed project / facility. Please see example. CERTIFICATION I certify to the best of my knowledge the information is true, complete, and accurate. Printed / typed name of applicant Date (month, day, year) Continue to page 2 if your proposed business is one of the following: wedding venue, event center, church, religious facility, restaurant / food service element, kennel, veterinarian clinic, campground, or youth camp. Reset Form ---PAGE BREAK--- Page 2 of 2 5. WEDDING VENUES / EVENT CENTERS Provide the number seats available for patrons (not the fire / safety occupancy level). Will there be a kitchen where meals will be prepared from scratch on-site? Yes No If yes, include a menu of items and method of cooking. Will meals will be catered and prepared off-site? Yes No Will dishes, glasses, and flatware be cleaned on-site? Yes No 6. CHURCHES AND RELIGIOUS FACILITIES Number sanctuary / worship area seats (not average attendance) – If pews, provide total length of a pew and the total number of pews. Will there be a kitchen where meals will be prepared from scratch on-site? Yes No If yes, how frequently? How many people will be served? Are meals prepared off-site and brought-in (e.g. potluck / carry-in / pitch-in)? Yes No If yes, will dishes, glasses, and flatware be cleaned on-site? Yes No Will there be any large gatherings or events? Yes No If yes, projected number of events Number of attendees per event Will food be served? Yes No Is there a day care facility outside of normal worship hours? Yes No If yes, how many children? How many employees? Is there an accredited school (not Sunday school) on-site? Yes No If yes, number of elementary students Number of secondary students Number of educators / staff 7. RESTAURANT / FOOD SERVICE ELEMENT Indicate the type of restaurant. Fast Food Restaurant open 24 hours Restaurant not open 24 hours Tavern / bar / cocktail lounge Number of seats Are meals prepared from scratch or pre-made ready to cook? Scratch Pre-made ready to cook Will glasses and dishes be washed? Yes No Is there a commercial dish washer? Yes No 8. KENNELS AND VETERINARY CLINICS Provide the following numbers for the proposed kennel: Cages Inside runs Outside runs Groomings per day Veterinary doctors Veterinary assistants Support staff Surgery rooms 9. CAMPGROUNDS / YOUTH CAMPS Provide the following applicable numbers for the proposed campground: Day campers and staff Youth campers and staff RV sites with or without sewer hookup RV dump stations Cabins within campgrounds: Without a restroom With a restroom With a restroom and kitchen Will there be a mess / dining hall? Yes No If yes, provide the number of seats Will there be a bath house? Yes No