Caroline County Health Department, Maryland

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
[E/H HOME PAGE] [FEE SCHEDULE] [FORMS/APPLICATIONS] [QUESTIONS-ANSWERS]

APPLICATION FOR ON-SITE SEWAGE DISPOSAL PERMIT

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) .
Additional phone# .	Closest town: .

C. Septic permit for: (select one and fill in the blanks)
  (__)New home (on vacant lot) will have ____bedrooms, ___bathrooms, ____people
  (__)New home (replacing old house) will have _____bedrooms, ____bathrooms, ____people
  (__)Commercial building (will have ____people using facility ___ days a week)
  (__)Existing home, want system sized for ____bedrooms
  (__)Tank or Grease Trap only

D. STAKE property lines, SRA, house, and well. If existing home, stake any future additions.

E. PROVIDE SITE PLAN showing: property lines, existing and/or proposed buildings(house, shed, garage, etc.),
wells, driveways, parking area, septic tank(s). RECOMMEND SURVEYOR STAKE AND PREPARE SITE PLAN.

F. Water supply is:
(__)existing from: (__)deep well (__)shallow well (__)municipal connection from ____________________
(__)proposed deep well, (___)proposed municipal connection from_____________________

G. Check payable to Caroline County Health Department in amount of $____________ (current fee)

H. Applicant certifies that the information provided is correct, and agrees as follows: That he/she: is authorized to
make this application on behalf of the property owner (attach authorization form if applicant not property owner), will
comply with all regulations of Caroline County, where are applicable hereto, will perform no work on the above
reference property not specifically described on this application, grants county officials the right to enter onto the
property for the purpose of inspecting the work permitted and posting notices.

I. Applicant's Signature:_____________________________________ Date:________________

NOTE: The Health Department's minimum specifications will be mailed to the address given on this application
unless instructed otherwise. ADDITIONAL FEES WILL BE CHARGED FOR MODIFICATIONS TO
SPECIFICATIONS SENT OUT OR IF ADDITIONAL SANITARIAN VISITS REQUIRED.