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Request for Access to Environmental Health Records

ALLEGAN COUNTY HEALTH DEPARTMENT
3255 - 122nd Ave., Suite 200, Allegan, MI 49010
Environmental Health Division
Phone: (269) 673-5415 / Fax: (269) 673-4172
Email: AlleganEH@allegancounty.org

This is a request for permission to receive or examine the official Allegan County records related to the location indicated below.
***No access to medical records or records being used for current legal action.***

NOTICE: DAMAGING, REMOVING OR MUTILATING HEALTH DEPARTMENT RECORDS IS A VIOLATION OF LAW

1. Name of person making request:

First Name: *This question is required.

Last Name: *This question is required.

Agency (if applicable):

Your Client (if applicable):

2. Location requesting related records for:

Street Address: *This question is required.

City: *This question is required.

Township/City/Village: *This question is required.

3. Please indicate what exact records are being requested (check all that apply):

Well Logs
Water Sample Results
Septic System Location
Septic Records - All

Well Records - All
Soil Boring Results
All Records
Other - Write In Please enter an 'other' value for this selection.

4. Please specify how you would like to access the records requested: *This question is required.

5. Pick up on date (allow a minimum of 5 business days for preparation): This question requires a valid date format of MM/DD/YYYY.

calendar

5. View on date (allow a minimum of 5 business days for preparation): This question requires a valid date format of MM/DD/YYYY.

calendar

5. Email to: This question requires a valid email address.

5. Fax to (###-###-####):

5. Mail to: