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   

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

SANITARY CONSTRUCTION AND/OR SEWAGE HAULER LICENSE APPLICATION

DIRECTIONS:   Complete items A-L, attach fee and certificate of liability insurance naming Caroline County Health
Department as a certificate holder to application. [click here for copy of County Regulations]

A. Name of business:____________________________________________________________

B. Owner of business
FIRST NAME, LAST NAME:___________________________________________________________

C. Mailing address:_______________________________________________________________
(Street addres or P.O. Box number, City, State, ZIP--this is where permit and renewal applications will be sent.

D. PHONES:   Day:__________________________    Fax:__________________________________    Cell:____________________________

E. TYPE OF LICENSE (select ONE of the following):
I___Installer only ($250 fee) H___Hauler only ($250 fee) H/I___Both Septage Hauler and Septic System Installer ($500 fee)
    Please make check or moneyorder payable to CAROLINE COUNTY HEALTH DEPARTMENT

F. List on back mechanical equipment you own to install and/or pump septic systems (make/model number/year):

G. INSTALLERS ONLY: Do you own a surveyors level?___

H. List on back other licenses (past or current) you hold or have held relating to sanitary construction and/or hauling septage.

I. INSTALLERS ONLY: Submit list of individuals in your firm who you are authorizing to sign on your behalf for permits
    to construct on-site septic systems (include typed names and their signatures, too)

J. Describe on back any experience you have relating to sanitary construction and/or hauling septage.

K. HAULERS ONLY: Attach copy of most recent truck inspection (if inspected in another Maryland county).   If your truck(s) not inspected by Maryland county, call 410/479-8045 to schedule an inspection--this application, insurance and fee must be received before or brought in at the time of inspection.  Written agreement to dump waste at approved facility required, too.

L. Signature:______________________________________        Date:_____________________

Leland Spencer, M.D., Health Officer
Comments to: belindar@dhmh.state.md.us $____________Paid on________________  Receipt#_________________   ID#______________
CFW 2010, September/br