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2. Date *
   Date
4. Establishment Name *
6. Establishment Address*
8. Phone Number*
10. Email Address*
14. Name of Person Requesting the Variance *
16. Email Address*
17. Phone Number*
21. Attach all required documentation below:
23. Provide the Chapter and Section of the Code you are requesting a variance from.*
25. Describe the requirement you are requesting a variance/waiver from. *
27. Explain why you are requesting variance/waiver from this part of the code. *
29. Explain why we should approve your request. Provide as much technical information as possible regarding your proposed alternative method. Include diagram or drawings with this explanation, if applicable. Include how the proposed alternative method will result in equivalent or superior protection of the public health. Additional Requirements for Specific Variance/Waiver Requests (if applicable)*
31. I hereby certify that the above information is correct and I fully understand that any deviation from the submitted request without prior permission from the Lexington Health Department may nullify the final approval.*

    1. Yes I understand
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33. 1. Receive an email copy of this form.
34. Email address

    This field is not part of the form submission.

35. Submit

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