FERGUS COUNTY ENVIRONMENTAL HEALTH SUBSURFACE WASTEWATER TREATMENT SYSTEM CERTIFIED SITE EVALUATOR APPLICATION
NAME
DATE
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
COMPANY NAME
BUSINESS PHONE
Format: (000) 000-0000.
CELL PHONE
Format: (000) 000-0000.
E MAIL ADDRESS
example@example.com
BUSINESS STREET ADDRESS
CITY
STATE
ZIP CODE
MAILING ADDRESS
CITY
STATE
ZIP CODE
YEARS OF EXPERIENCE
ANY CURRENT OR PAST LICENSES?
YES*
NO
* If yes enter information below:
LICENSE #
LICENSE YEAR
LICENSING DISTRICT NAME
CITY
STATE
LICENSE #
LICENSE YEAR
LICENSING DISTRICT NAME
CITY
STATE
FOR OFFICE USE ONLY:
APPLICATION RECEIVED BY:
First Name
Last Name
DATE
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
$50 CERTIFIED INSTALLERS APPLICATION FEE PAID?
YES (enter check # below)
NO
CHECK #
TEST DATE
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
SCORE
PASSED?
YES
NO
LICENSE #
Preview PDF
Submit
Should be Empty: