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12/18/2024 CAYUGA COUNTY HEALTH DEPARTMENT 8 Dill Street, Auburn, NY 13021 (315) 253-1405 2026 APPLICATION FOR BUSINESS PERMIT TO INSTALL OR REPAIR SEPTIC SYSTEMS *This permit is valid for calendar year 2026* To be completed by all persons or corporations engaged in the business of installing or repairing septic systems, including septic tanks, or pumping out septic tanks pursuant to Article V, Section III of the Cayuga County Sanitary Code. The fee for the permit is $100.00. Please make checks payable to the Cayuga County Health Department and return with the completed application. 1. Business Name 2. Business Mailing Address Street City State, Zip Business Phone # 3. Owner Name 4. Owner Address 5. Type of Business (Check all that apply) Pumps Out Septic Tanks ____Installs and/or Repairs Septic Systems, including tanks ____Certified by Eljen Other Certifications 6. Liability Insurance - Company Name Company Address Policy Amount of Coverage 7. Waste Haulers - Transporter’s Part 364 Permit Number Disposal Sites: I hereby certify that, to the best of my knowledge, the information that I have provided in this application is current and correct. I certify that I am familiar with the requirements of the Cayuga County Sanitary Code. I understand that the Health Department must review and accept all septic system plans for new and repaired septic systems, including tank installations, before installation or repair of the septic system or tank. I also understand that if I do not comply with the requirements of the Cayuga County Sanitary Code, I will be subject to penalties up to $2,000.00 per violation and my business permit may be revoked. Signature of Applicant Date Approved by Environmental Health Division Date