Board of Health
S. Perrine Dey, DVM, Chairman
Margaret Jahn, Health Officer 732-294-2061
bohuftnj@optonline.net
Ref. No.: SWT:_____
SOIL EVALUATION WITNESSING APPLICATION
IN ACCORDANCE WITH BOARD OF HEALTH ORDINANCE NO. BH 3-04
Applicant’s Name:________________________________ Date of Application:_______________
Applicant’s Phone No.____________________________________________________________
Billing Address: _________________________________________________________________
City State Zip
Site Address: __________________________________________ Block: _______ Lot:________
Engineer Performing Work: ________________________________________________________
Engineer’s Address: ______________________________________________________________
City State Zip
(No. of Logs) _______ x $40.00 (per log) = __________________
(Travel Expenses) _______ x $31.50 (per day) = __________________
TOTAL DUE: __________________
ADDITIONAL WORK PERFORMED:
(No. of Logs) _______ x $40.00 (per log) = __________________
(Travel Expenses) _______ x $31.50 (per day) = __________________
TOTAL DUE FOR ADDITIONAL WORK:______________________
Applicant’s or Representative’s Signature: ____________________________________________
Inspector’s Initials: _______________________________________________________________
Please note: If you are requesting the work to be done within the week you are processing this
application the fee must be a certified check, money order, or cash. A personal check can be
used if the tests are scheduled the following week. Applicants must call Freehold Area Health
Department, (our contracted health department - 732-294-2060), to schedule soil witnessing.