Sanitarian Approved Initial:	 Date:  	

Emailed: 	

Northeast District Department of Health
69 South Main Street, Unit 4
Brooklyn, CT 06234
Phone - (860) 774-7350 / Fax - (860) 774-1308
www.nddh.org                email@nddh.org 

CAMPGROUND APPLICATION

Name of Establishment: _______________________________________________________
Address: ____________________________________________________________________
Mailing Address (if different): __________________________________________________
City: ________________________ State: ____ Zip: ________ Phone: __________________
Fax: ______________________ Billing Email Address: ___________________________________

Owner: _________________________________________Phone: _____________________
Mailing Address______________________________________________________________
City: ______________________ State: ____ Zip:_________ Home Phone:_______________	

Name of Manager: ____________________________________________________________
Type of Campground:	Natural ___________ Family ____________
Season Start Date: __________	Season End Date: ___________
Water Supply: Private_____ Public_____ 	Sewage Disposal: Septic System____ Public____
If private, what is the date of last analysis? ___________
If septic, what is the date last pumped? ______________

Total Number of Camp Sites: ____
______# of Restricted camp sites	
______# of Water hook-ups	
______# of Water/sewer hook-ups	
______# of Remote sites	

Is food service provided? Yes_____ No_____

Are bathing facilities available?  Yes_____ No_____ 
If yes, what type(s):	Swimming Pool ______ Natural (Pond, Lake, Other) ______
If there is a swimming pool, list information about the filters, automatic chlorinators, etc.:
__________________________________________________________________________________
__________________________________________________________________________________

Please complete reverse side of application

Sanitary Facilities:

Number of Flush Toilets:  	Male ________ Female ________
Number of Showers:		Male ________ Female ________
Number of Sinks:		Male ________ Female ________
Number of Privies:		Male ________ Female ________

Sink Waste:

Number of Individual Leaching Pits/Galleries: ______________
Number of Sites Covered: ______________________________

Sewage Waste:

Number of Holding Tank Dumping Station(s): ______________
Method of Pumping or Emptying Holding Tanks: ___________

List any changes made in the past year? 

Print Name: ______________________________________________________________________
Signature: _____________________________________         Date: _________________________
Signature: _____________________________________         Date: _________________________
Signature: _____________________________________         Date: _________________________

NDDH Use Only		
Date: ___________ Fee: _______ Check # _________     CC    E-Check     Cash     Receipt #_________________   
Date: ___________ Fee: _______ Check # _________     CC    E-Check     Cash     Receipt #_________________