Information Request Form

4. Frederick County Health Department - Environmental Health Services
   350 Montevue Lane, Frederick, MD 21702-8245
6. 301-600-1726 (information) 301-600-3180 (fax)

   Email to InformationResearchRequests@Frederickcountymd.gov

8. Date
   Date
10. This document serves as a formal request for information on the property located at:
12. Street Address
13. Subdivision Name (if known):
15. City
16. State
17. Zip
19. Lot #
20. Section
21. Block
23. Tax Map
24. Parcel
25. Year Built
27. Well Identification Tag Number (if requesting well information)

    (tag should be attached to well casing)

29. ***ALL INFORMATION MUST BE PROVIDED OR REQUEST WILL NOT BE PROCESSED*** 
    Name of property owner at the time of well and/or septic installation, or at the time of repair or replacement. It is the requester's responsibility to provide the necessary information for our staff to complete the research. A deed search may be required prior to form submission in order to locate information requested.

31. Real Property Search

    http://sdat.dat.maryland.gov/RealProperty/Pages/default.aspx

32. Maryland Deed Search

    https://mdlandrec.net/main/index.cfm

34. Current Owner's Full Name*

    
    

    AND

36. Previous Owners' Full Name (back to 1950 or year installation occurred)*

    ***This information must be provided or request will NOT be processed***

38. Provide the following information:
40. EXISTING PROPERTY WITH DWELLING

    1. well completion report
    2. existing septic location
    3. bedrooms permitted with current septic system
    4. other (enter below)
41. NEW PROPERTY WITH NO DWELLING

    1. well completion report (for developed property)
    2. proposed septic location (new lots)
    3. total bedrooms allowed (perc results)
43. other
    (be specific)
45. Requested by: First Name*
46. Last Name
48. Address*
50. City*
51. State*
52. Zip*
54. Phone (primary)*
55. Phone (secondary)
56. Fax (optional)
58. Information to be

    1. picked up in office
    2. faxed
    3. mailed
    4. emailed (enter below)
60. Email Address
62. Note

    Requested information will be returned to you within a minimum of ten (10) working days of receipt. Percolation verification and other technical requests may take up to 30 business days.

64. Note:
    INCOMPLETE REQUEST FORMS WILL NOT BE PROCESSED.
Leave This Blank:


66. 1. Receive an email copy of this form.
67. Email address

    This field is not part of the form submission.

68. Submit Submit and Print

* indicates a required field