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Health Officer’s Report Application for Subdivisions

Department of Health · St. Joseph County, Indiana

Editable official PDF

Edit the agency’s original form, save your draft, attach documents, and review your completed PDF before signing or ordering delivery.

Print and mail service is available for your prepared packet. Review the destination and the agency’s acceptance requirements before ordering. Government payment is separate from document and postage charges.

Applicant fields are mapped to the source PDF. Agency-only fields are reserved.

Official form and instructionsPay the agency directly
Your application steps6 steps · Department of HealthView steps
  1. 1Prepare your answersComplete here

    Edit and save your answers on the official PDF.

    Official source
  2. 2Add supporting documentsComplete here

    Attach the supporting records listed by the agency. Check that every page is legible and complete.

    • Attach a soil report consistent with Department of Health requirements.
    • Attach the plot plan, support datasheet, and other required information as submitted to Area Plan Commission.
  3. 3Review and signPrepare here, finish outside

    Complete each applicable applicant signature after reviewing the full declarations. Required notary, professional and witness signatures remain separate.

  4. 4Choose paymentPrepare here, finish outside

    $125 per lot, maximum $875, for a Health Officer report; additional charges may apply. Government fees are separate from the optional prepared PDF and postage. Review the exact amount and recipient before authorizing a check.

    Pay the agency directly
  5. 5Submit or order deliveryPrepare here, finish outside

    Attach a soil report consistent with Department of Health requirements. Attach the plot plan, support datasheet, and other required information as submitted to Area Plan Commission. The original PDF is available to prepare the application. The official payment form instructs users to submit their application through DocuSign first. For a paper/PDF filing, coordinate payment with the department before using that payment-only page.

    Official submission instructions
  6. 6Keep your receiptComplete here

    Save your agency confirmation and payment receipt. Track any mailing from My applications. Delivery does not mean the agency approved your application.

Official requirements and sources

Complete your application

Required fields are marked *. Fields follow the agency’s published form. Save your work before leaving this page.

Fill in the official form

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Page 1 of 1 · 31 editable blanks
St. Joseph County Department of Health “To promote health and wellness with compassion and integrity through partnerships, education, protection, and advocacy for all who reside in and visit St. Joseph County.” APPLICATION FOR HEALTH OFFICER REPORT FOR SUBDIVISION Applicant Information: Name: Address: City: State: Zip: Work #: Fax #: Email: Reports are sent via email to Applicant and Area Plan. Please include name/email address of others you wish to receive reports: Owner: Address: City State Zip Work #: Fax #: Email: Subdivision Name: Lot numbers created by this action: Type of Request: Check type and complete number of lots. Major: # of lots: Minor: # of lots: Replat: # of lots: Anticipated use of subdivision: Residential Commercial Other: Site Information: Street name/s: City: Zip: Distance from municipal service to nearest property line: Water Sewer Required Attachments: Attach a soil report consistent with Department of Health requirements. Attach the following as submitted to the Area Plan Commission: Plot plan Support datasheet Other information specified by the Department of Health (See process for obtaining Health Officer Reports). Please send all electronic correspondence to envirohd@sjcindiana.com For Department of Health Use Only: Application #: Signature of Applicant or Representative Date Transaction # Date: Printed name

Select any highlighted blank to type. A larger copy of the selected question appears here.

Review every page before signing. Professional, agency and notary signature areas stay reserved.Original blank form