Variance And Waiver Request Form - Georgia Department Of Public Health
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3Georgia Department of Public Health
Environmental Health Section, Land Use Unit
th
2 Peachtree Street, NW. 13
Floor
Atlanta, Georgia 30303-3186
404-657-6534
Date:
1. Petitioner
Name:
Address:
Property location:
Phone number:
Contact Person:
Attorney or person representing petitioner:
2. Rule(s) from which a variance or waiver is requested.
3. Type of action requested.
a. variance
b. waiver
Page 1 of 3
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