Fillable SEWAGE PUMPING/HAULING PERMIT APPLICATION (Contra Costa Health Services)

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SEWAGE PUMPING/HAULING PERMIT APPLICATION (Contra Costa Health Services)

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The SEWAGE PUMPING/HAULING PERMIT APPLICATION (Contra Costa Health Services) form is 1 page long and contains:

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  • 5 check-boxes
  • 26 other fields

Country of origin: US
File type: PDF

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CONTRA COSTA
ENVIRONMENTAL HEALTH DIVISION
2120 DIAMOND BOULEVARD, SUITE 100
CONCORD, CA 94520
(925) 608-5500 FAX (925) 608-5502
www.cchealth.org/eh
SEWAGE PUMPING/HAULING PERMIT APPLICATION
Type of Work (Check all that apply):
Septic System Pumper Vehicle (44) Vault Waste Pumping (57)
Portable Toilet Pumper Vehicle (55) Septic Waste Hauling, only (59)
Sewage Pumper Company (45)
The registration and permitting of the business and the pumper vehicles is to ensure the businesses are
properly extracting and disposing the liquid waste from septic tanks, individual sewage systems, holding
tanks, pit privies, cesspools, sewage seepage pits, and chemical toilets.
Provide a copy of current DMV registration of pumper vehicle
PLEASE PRINT CLEARLY. ALL FIELDS MUST BE COMPLETED.
Legal Owner’s Name
Legal Owner Address
City
State
Zip Code
Email(s)
Emergency Phone
FAX Phone
Driver License #
Care Of
Business Address
City
State
Zip Code
Business Email(s)
Business License #
License Plate #
VIN#
Tank Capacity (Gal.)
Address – Equipment Parking:
Chemical Toilets: Company Name
Storage Location:
Unit Number(s):
The undersigned hereby applies for a Permit to Operate and agrees to operate in accordance with all applicable state and local
regulations, laws, and such inspection procedures needed to ensure compliance. Payment of the required fee and late penalties,
if any, to secure a valid permit is required before commencing or continuing operations. Failure to do so may result in a
misdemeanor citation, permit suspension/revocation proceedings, and/or closure. Notify Contra Costa Environmental Health
Division of any changes in the type of business activity, name, billing address, or ownership by calling the number above.
PERMITS ARE NOT TRANSFERABLE.
Applicant Name (Please Print Clearly)______________________________________________________________________
Signature of Applicant___________________________________________________________________________________
FOR OFFICE USE ONLY
FA #:
PR #:
P/E
42
REHS:
Amount Due: $
Amount Paid: $
Receipt #:
XR
Received By:
Check #:
CASH
Credit Card: MC VISA
Date Received:
Supervisor:
(Revised 10/2019)
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SEWAGE PUMPINGHAULING PERMIT APPLICATION (Contra Costa Health Services)

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Completed 10 January 2021

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