Systems Contractor: Application for a License to Install Small Wastewater Systems

Please check appropriate category:(Required)

Individual

Corporation

Firm

Fee:(Required)

New: $375

Renewal: $185

Name of Business:(Required)

Business Address:(Required)

Street Address Address Line 2 City State ZIP Code

Phone Number:(Required)

Cell Phone Number:(Required)

If a corporation or firm, give the proper corporation/firm name, agent for service, and corporation/firm officers:(Required)

Name of Applicant:(Required)

First Last

Mailing Address:(Required)

Street Address Address Line 2 City State ZIP Code

Phone Number:(Required)

Cell Phone Number:(Required)

Email Address:(Required)

Enter Email Confirm Email

THE APPLICANT CERTIFIES THAT HE/SHE IS FULLY ACQUAINTED WITH THE LARAMIE COUNTY SMALL WASTEWATER SYSTEMS REGULATIONS, SECTION 16, AND WILL CONDUCT THE BUSINESS IN COMPLIANCE WITH THE REGULATIONS.

Applicant's Signature:(Required)

Draw your signature.

Date(Required)