Caroline County Health Department
Division of Environmental Health
403 S 7th Street, P.O. Box 10, Denton, MD 21629
Hours 8-5p.m., M-F; Phone: 410/479-8045    FAX: 410/479-4187

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FREEDOM OF INFORMATION ACT REQUEST FOR RECORDS SEARCH

Complete sections A-C, incomplete applications will not be processed.   PLEASE PRINT.  Use separate forms
for separate parcels.   Please allow 30 days processing time.
A. Applicant's Name and mailing address                         B. Property Description                
Applicant's Name
.		 911 address of parcel
.
Mailing address (Street address or P.O. Box #)
.		 Map, Block, Parcel numbers
.
Mailing address (City/State/Zip)
.		 Lot # and name of subdivision (if applicable)
.
Applicant's phone number
.		 Property owner
.
Fax records to
.
 Records requested:   ___perc     ___septic    ___well
___Other (specify):
Under State Government Article 10-611-628 a records search is requested for property noted above.

Applicant’s Comments:



If copies made, I understand that a minimum $1 fee will be charged and an additional 25 cents for each copy over 4.
No fees assessed for faxes.

C. Applicant's signature:                                   Date:

Please do not write below this line, for Health Department Use only

    paid   Receipt #                             Date retrieved:                              Retrieved by:
FILE CONTAINED INFORMATION RESTRICTED BY LAW?___     IF YES, DESCRIBE ACTION BELOW: