This authorization form must be completed and signed by the owner. Attach this form
with a site plan and bring to the Environmental Health Office to fill out appropriate application--OR select
an application below and have owner sign that application instead of this form. An explanation of applications follows:
PERC TEST is required when planning to build on a vacant lot that does not have a
current perc approval. This application WILL take longer than 30 days to process. Refer
to the application for more information.
SANITARY CONSTRUCTION PERMIT is required when planning to install a new septic system or
repair/replace old septic system. Plan for 30 days processing time. Refer to application for
more information.
WATER/SEWER VERIFICATION is required when property has existing water and/or sewer and
applicant is planning to build (anything), open home occupation business, or subdivide. Plan for
30 days processing time. Refer to application for more information.
PROPERTY STATUS REPORT is required when an up-to-date report is needed concerning the
status of the perc test on the property in question or proposed sewage reserve area (SRA)changes. Plan
for 30 days processing time. Refer to application for more information.
MAIL ORIGINAL TO: CCHD-Environmental Health, P.O. Box 10, Denton, MD 21629
CANNOT ACCEPT ELECTRONIC (FAXED) SIGNATURES
PLEASE PRINT
Dear Caroline County Health Department:
I _______________________________________ (owner) give permission for
________________________________________ to apply on my behalf for a:
- __perc test
- __property status report
- __septic permit
- __water/sewer verification
CHECK ALL THAT APPLY
for my property located at: ______________________________________ Road
Tax Map____, Block___, Parcel_____, Lot____; Name of Subdivision:
Owner's current
Mailing address:________________________________________________
(Street or P.O. Box, Town, State, ZIP, and phone)
Owner's signature:__________________________ Date:__________
CCHD:AUTHORIZATION FORM\REVISED 10/05