HEALTH ENQUIRY
Environmental Planning and Assessment Act 1979, Food Act 2003, Public Health Act 2010,
Local Government Act, 1993
Locked Bag 155, Coffs Harbour 2450;
Customer Service Centre, 2 Castle Street, Coffs Harbour
Email: Phone: (02) 6648 4000
Website: ABN 79 126 214 487
This form may be used to enquire about obtaining information or to request an inspection report associated with Council’s regulation of health related functions including:
  • Pre-opening / commencement of use inspection report for food or health regulated business;
  • Pre purchase inspection report associated with food or health regulated business;
  • Pre purchase inspection of an on-site sewage management system; and
  • Other general related enquiries.

1.Details of the applicant
It is important that Council is able to contact you if more information is required. Please give as much detail as possible.
Mr Ms Mrs Dr Other:
Given name/s / Surname
Company/organisation / ABN
Postal address
Suburb or town / State / Postcode
Daytime telephone / Fax / Mobile
Email address

Health Enquiry (FRM –E139) 02/01/2018

2. Type of Enquiry
Nominate relevant Health related matter that your enquiry relates to:
Development Application No:
Pre-opening / commencement of use inspection and report:
Food businessHairdressing salonBeauty Salon or skin penetration business
Pre purchase inspections:
Food businessHairdressing salonBeauty Salon or skin penetration business
On-site Sewage Management System
Other (please specify):
Provide a brief explanation of the information you seek to obtain from Council. Property specific information will not be provided unless this application has the consent of the property / business owner or from a practicing conveyancer or solicitor in association with a contract for sale.
……………………………………………………………………………………………………………………………………
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3.Identify the land and/or name of business
Complete following where applicable:
Name of Business
Unit/street no. / Street
Suburb, town or locality / State / Postcode
Lot/DP or Lot/Section/DP or Lot/Strata no.
4. Applicable fees and charges
To view the applicable fees and charges associated with this application, please refer to Council’s adopted fees and charges at
5. Privacy and personal information protection notice
  • this information is required to process your request and will not be used for any other purpose without seeking your consent, or as required by law;
  • your information may comprise part of a public register related to this purpose;
  • your application will be retained in Council’s Records Management System and disposed of in accordance with the Local GovernmentDisposal Authority;
  • your personal information can be accessed and corrected at any time by contacting this Council.

6. Applicant’s Signature/s
I declare that to the best of my knowledge all particulars supplied by me are correct and completed. I understand that inaccurate or false statements may cause my application to be delayed or rescinded.
Signature/s: …………………………………………………………………………… Date: ……/……./…….
7.Property / Business owner(s) consent and signature
If your application requires Council to undertake an inspection of a property or business and you are not the owner of the property or business the following consent is required:
As owner(s) of the above property / business, I/we consent to this application and grant permission for Council's Officers to enter the property for the purpose of assessment of the application.
Name of Property/BusinessOwner(s) / Signature(s) / Date
Office Use Only
Date received / Application fee / Receipt No.

Health Enquiry (FRM –E139) 02/01/2018