Public Health Environmental Public Health
700 South 2nd Street Room #301 1800 Continental Place
Mount Vernon, WA 98273 Mount Vernon, WA 98273
(360) 416-1500 Fax (360) 416-1501 (360) 416-1500 Fax (360) 416-1565
ON-SITE SEWAGE SYSTEM PUMPER
CERTIFICATE APPLICATION
1) New Certificate; a) Provide Verification of Experience/ Exam results; b) Provide evidence of
$20,000 Surety Bond; c) Submit Fee according to current Schedule of Charges payable to
Skagit County Department of Public Health.
2) Renewal; a) Provide evidence of $20,000 Surety Bond; b) Submit Renewal Fee (Invoice
enclosed) payable to Skagit County Dept of Public Health c) Provide evidence of 1 CEU of
Continuing Education (or equivalent).
PLEASE PRINT
Business Name:
Mailing Address:
City/Zip:
Phone/Email: ____________________________________________________
Names of Pumpers: ____________________________________________________
License # of Truck(s): ____________________________________________________
I______________________________________, of
(Print Name) (Business Name)
hereby submit both my application and required application fee for the profession of On-site Sewage System Pumper,
which includes the cleaning out, emptying, pumping out or disposing of the contents of any septic tank, cesspool,
sewage pit, vault privy, chemical toilet, holding tank, or other means of sewage disposal. I have received, have read
and understand the Rules and Regulations of the Skagit County On-Site Sewage Code governing on-site sewage
systems
Signature: ______________________________________________Date:____________
Skagit County Department of Public Health
Jennifer Johnson, Director
Howard Leibrand, M.D., Health Officer
