An application for a license must be made to the department on forms provided by the department. The application must contain:
(1) the full name and business address of the applicant;
(2) a list of the counties in which business is to be conducted and a list of disposal sites that the applicant intends to use during the permit year;
(3) for each disposal site listed pursuant to subsection (2), a certification by a local health officer or the local health officer's designated representative in the county in which the disposal site is located that the site meets all applicable state and local requirements;
(4) written permission to use each proposed disposal site signed by the owner, manager, or other person authorized to give permission to use the disposal site; and
(5) any additional information required by rule.