COUNTY OF RANDOLPH
Health Department
204 E Academy St - Asheboro, NC 27203
LOCAL TELEPHONE NUMBERS
Asheboro: (336) 318-6262 ● Archdale/Trinity: (336) 819-3262
http://www.randolphcountync.gov
Consultation Visit Application (EH-CV) Rev. 9/5/2019
CONSULTATION VISIT APPLICATION
Applicant: ________________________________ Date: ____________________________________
Address: __________________________________ Application #: ______________________________
City, ST ZIP _______________________________ Parcel number: ____________________________
Owner: __________________________________ Contact name: ____________________________
Address: _________________________________ Contact phone: ____________________________
City, ST ZIP ______________________________ Contact e-mail: ____________________________
LOCATION INFORMATION:
Location: ________________________________________________________________________________
Subdivision: ______________________________ Lot number: ______________________________
CONSULTATION INFORMATION:
Reason for Consultation Visit: _______________________________________________________________
If other, specify reason: ____________________________________________________________________
TOTAL APPLICATION FEE: _________________
COMMENTS: ____________________________________________________________________________
________________________________________________________________________________________
AUTHORIZATION TO PROCEED:
I have read this application and certify that the information provided herein is true, complete and correct.
Authorized County and State officials are granted right of entry to conduct necessary inspections to determine
compliance with applicable laws and rules. I understand that I am solely responsible for the proper identification
and labeling of all property lines and corners and making the site accessible so that a complete site evaluation
can be performed.
_______________________________________ _______________________________________
Signature of property owner/legal representative* Date
*You must provide documentation to support claim as owner’s legal representative.
Select a reason for consultation visit.
click to sign
signature
click to edit
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