APPLICATION FOR SOIL/SITE EVALUATION(Perc test), see Application Instructions
| A. Applicant's Name and mailing address | B. Property Description |
|---|---|
| Applicant's Name . |
Property owner (if applicant not current owner) . |
| Mailing address: Street address or P.O. Box # |
Enter property from what road? . |
| Mailing address: City/State/Zip |
MAP BLOCK PARCEL . |
| Applicant's phone number . |
LOT # and name of subdivision (if applicable) . |
C. Existing parcel (check all that apply)...
...( ) is vacant and is ______ acres.
...( ) has a ____ bedroom dwelling and parcel is _____ acres.
...( ) has a permitted septic system (copy of permit attached).
...( ) has a very old septic system--no permit available.
...( ) has a permitted well (copy of well completion report attached). Well is ( )deep ( )shallow.
...( ) has a very old well--no permit available. Well is ( )deep ( )shallow
D. Proposed use (check all that apply)...
...( )Commerical-Water usage:____________________
...( )Residential - # of bedrooms will be______
...( )Planning to make ____ building lots
...( )Private Well
...( )Public water from:_____________________
E. How many _______ and what type(s) of Test are you requesting:
___Soil Test(pits); ___Wet Season(pipes); ___Transfer Development Right; ____Sand Mound
Enclose check or money order payable to "Caroline County Health Department" in the amount of $*
Enclose scaled site plan showing location of pits and/or pipes (*see fee schedule to determine amount due).
F. AUTHORIZATION: The applicant hereby certifies and agrees as follows:
(1) he/she is authorized to make this application;
(2) the information is correct;
(3) will comply with the regulations of Caroline County which are applicable hereto;
(4) will perform no work on the property not specifically described in this application;
(5) grants County officials the right to enter onto the property for the purpose of inspecting the
property, work permitted and posting notices;
(6) has read and understood the following
"Soil and Site Evaluation General Information",
"Site Preparation" and
"Application Instructions";