CAROLINE COUNTY HEALTH DEPARTMEN

CAROLINE COUNTY HEALTH DEPARTMENT

Division of Environmental Health (410) 479-8045

P.O. Box 10, Denton, MD 21629

Located at 403 S 7^th Street, Denton (FAX: (410) 479-4187

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

SEWAGE AND WATER ALLOCATION CERTIFICATE

Town to complete sections A-D, incomplete applications will not be processed. PLEASE PRINT. Use separate forms for separate parcels. FAX THIS FORM TO 410 479-4187. Please allow 30 days processing time.

A. Town’s Name and Mailing Address	B. Property Description
Town’s Name:	Road Name: .
Street/P.O. Box:	Map - Block - Parcel Numbers .
City/State/ZIP:	Lot # .
TOWN’S FAX#	Property Owner .
Sewer/water supply extension needed? (Y) (N)	Name of Project .

C. Proposed Project:

__ Single family dwelling (Number of lots:__________________)

__ Multi-family dwelling (Number of units:__________________)

__ Commercial/Industrial; Type of business:___________________________________________________ #employees:_____ Sq Footage:_______________

Estimate Wastewater Flow Requirement:____________gallons per day per unit/lot (Total gpd for project:__________________________________________)

D: Town Use:

To the Health Department: This available flow has been reviewed and is granted to the applicant for the proposed use.

If not utilized, this allocation expires:______________________________________________ (unless extension granted).

Approved by:_____________________________________________________________________________________________

Signature of Town Representative Date Printed Name

HEALTH DEPARTMENT USE:

Approved by:_____________________________________________________________________________________________

Signature of Sate Representative (Health Department) Date Printed Name

THIS APPROVAL HEREBY CONFIRMS THE REQUIREMENTS OF THE ANNOTATED CODE OF MARYLAND ENVIRONMENTAL ARTICLE §9-512 HAVE BEEN MET. THE APPROVAL AND ISSUANCE OF ANY BUILDING PERMIT FOR THE PROJECT IS THE JURISDICTION OF THE TOWN.