SOMERSET COUNTY HEALTH DEPARTMENT
Environmental Health Section 
7920 Crisfield Highway 
Westover, Maryland 21871
Phone:  443-523-1730   Fax: 410-651-4083

$250 FEE IS DUE AND PAYABLE AT TIME OF APPLICATION.  THIS IS A NON-REFUNDABLE FILING AND PROCESSING FEE.

SOIL EVALUATION APPLICATION

OWNER_______________________________APPLICANT___________________________________

ADDRESS ____________________________  ADDRESS___________________________________

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PHONE_______________________________	PHONE___________________________________

TAX MAP______________  BLOCK______________  PARCEL____________  LOT_____________

LOCATION________________________________________________________________________

LOT SIZE_________________    SOIL TYPE_________________    MAN.AREA_____________

RESIDENTIAL_________ COMMERCIAL_________ SINGLE LOT_________  SUBDIVISION_______

* * *   D O   N O T   W R I T E   B E L O W   T H I S   L I N E   * * *

PERCOLATION TEST

DEPTH_________________ WATER TABLE________________ WATER ADDED_________________

TIME FIRST INCH_____________________________ HOLE DIAMETER/SIZE________________

TIME SECOND INCH___________________________  CONVERTED RATE____________________

SOIL PROFILE

DEPTH			   COLOR			DESCRIPTION
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TEST CONDUCTED BY________________________________________ DATE__________________

APPROVED__________________________________  DISAPPROVED_________________________