Fillable CONSULTATION VISIT APPLICATION COUNTY OF RANDOLPH (Randolph County)

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CONSULTATION VISIT APPLICATION COUNTY OF RANDOLPH (Randolph County)

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COUNTY OF RANDOLPH
Health Department
204 E Academy St - Asheboro, NC 27203
- LOCAL TELEPHONE NUMBER -
Asheboro: (336) 318-6262 - Greensboro/Liberty: (336) 218-4262 - Archdale/Trinity: (336) 819-3262
http://www.co.randolph.nc.us
CONSULTATION VISIT APPLICATION
Applicant: ______________________________ Date: _________________________
Address: ______________________________ Application #: _________________________
City, ST ZIP: ______________________________ Parcel number: _________________________
Owner: ______________________________ Contact: _________________________
Address: ______________________________ Contact Phone: _________________________
City, ST ZIP: ______________________________
LOCATION INFORMATION:
Address: ______________________________
Subdivision: ______________________________ Lot Number: _________________________
CONSULTATION INFORMATION:
Reason for Consultation Visit: ____________________________________________________________
If other, specify reason: ____________________________________________________________
COMMENTS: _________________________________________________________________________
Total application fee: __________________
AUTHORIZATION TO PROCEED:
I have read this app
lication 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.
_______________________________________ _______________________________________
Authorized County Official Signature of Contractor or Owner
Consultation Visit Application (EH-CV) Manual Application
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CONSULTATION VISIT APPLICATION COUNTY OF RANDOLPH (Randolph County)

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Completed 6 August 2020

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