Talbot County Health Department

TALBOT COUNTY HEALTH DEPARTMENT

APPLICATION FOR SANITARY CONSTRUCTION/SEPTIC TANK SERVICING

I/WE ______

ADDRESS______ZIP CODE______PHONE______

Do hereby make application for the following license or licenses in Talbot County, Maryland, in conformity with the “Sanitary Construction Regulations of the Board of Health of Talbot County”.

1. Septic Tank Systems Construction License $200.00

2. Septic Tank Servicing License $200.00

Total Fee Enclosed: $______

In making this application, I/WE hereby agree to comply with all provisions of the Sanitary Construction Regulations of Talbot County, and the Maryland Department of Environment.

Date: ______Signed: ______

Title: ______

Address: ______

______

FOR OFFICE USE ONLY

APPROVED BY: ______DATE: ______

LICENSE NUMBER ISSUED: ______TYPE OF LICENSE: ______

BONDING COMPANY: ______

COMMENTS:______

PLEASE MAKE CHECK PAYABLE TO: TALBOT COUNTY HEALTH DEPARTMENT and mail to:

TALBOT COUNTY HEALTH DEPARTMENT

OFFICE OF ENVIRNOMENTAL HEALTH

215 Bay Street, Suite 4

EASTON, MD 21601

Revised 09/13