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

MOBILE HOME PARK PERMIT APPLICATION

1) Owner_____________________________________     2) Phone___________________

3) Mailing/Billing Address_________________________________________________________
                  Street or P.O. Box Number      City      State       ZIP

4) Park Name:__________________________________     5) Park Phone #________________

6) Park Location_______________________________________________________________
          (911 address)

7) Number of Mobile Home Spaces_____________    8) Size of Park_________acres

9) Sewage Meter Reading:________________     10) Water Meter Reading:_______________

11) Workmen's Compensation Insurance with:_______________________________________

12) Name of Park Manager:_____________________________________________________

APPLICANT'S STATEMENT: Application is hereby made for a permit to operate a Mobile Home
Park, in accordance with the Maryland State Department of Health and Mental Hygiene
Regulations 10.16.02 governing such establishments.

13) Applicant's signature X___________________________    14) Application Date:__________
     APPLICANT'S PRINTED NAME: