Fillable COUNTY OF RANDOLPH Health Department 204 E Academy (Randolph County)

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COUNTY OF RANDOLPH Health Department 204 E Academy (Randolph County)

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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
COMPLIANCE VERIFICATION APPLICATION Page 1 of 1
COMPLIANCE VERIFICATION APPLICATION
Applicant: ________________________________ Date: ____________________________________
Address: __________________________________ Application #: ______________________________
City, ST ZIP _______________________________ Parcel number: ____________________________
Owner: __________________________________ Contact name: ____________________________
Address: _________________________________ Contact phone: ____________________________
City, ST ZIP ______________________________ Contact e-mail: ____________________________
LOCATION INFORMATION:
Address: ________________________________________________________________________________
Subdivision: _____________________________ Lot Number: ______________________________
VERIFICATION INFORMATION:
Reason for Verification: ____________________________________________________________________
Description of Work: ______________________________________________________________________
COMMENTS: ____________________________________________________________________________
________________________________________________________________________________________
Total application fee: $50.00
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.
_______________________________________
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COUNTY OF RANDOLPH Health Department 204 E Academy (Randolph County)

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Completed 18 May 2021

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