Cherokee County Health Department
Application for Inspection

www.cchdtexas.org

  
 

Return both the completed application and fee made payable to the Cherokee County Health Department.
Mail to: 593 North Main Street  Rusk, Texas  75785.
 

FAILURE TO PROVIDE ALL INFORMATION REQUIRED WILL DELAY INSPECTION.   

 

INSPECTION CANNOT BE CONDUCTED UNTIL APPLICATION AND FEE ARE RECEIVED.

 

Please call (903) 683-2990 to schedule day and time of inspection.

  
 
  Name under which Business is operated (DBA):____________________________________________
 

Physical Address:____________________________________________________________________

                             Street Address (If route, give directions on reverse)      City                     Zip

 

Mailing Address (if different): ____________________________________________________________
 

City, Zip Code:  ______________________________________________________________________


Telephone Number at above address:  (     )________________________________________________
 

Contact Person: _____________________________________________Title:____________________

 

 

ESTABLISHMENT TYPE:     [    ]  Adult Foster Care Home     [     ]  Foster Care/Adoptive Home     [    ]  Environmental Inspection

 

An inspection fee is due per inspection required by your licensing entity.

 

INSPECTION FEE -- $50.00

 

          

                                                                                              Fee paid        $______________

 
 
  I certify that the information furnished is true and correct to the best of my knowledge.
 
       
Printed Name of Applicant  

Title
     
       
Signature of Applicant  

Date

(Environmental Inspection Form 05/08)