Form En-651-010 - Application For On-Site Wastewater Treatment System Designer Practice Permit Page 2

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STATE OF WASHINGTON
BOARD OF REGISTRATION FOR
PROFESSIONAL ENGINEERS AND LAND SURVEYORS
P.O. BOX 9649
Board Staff
(360) 664-1575
OLYMPIA, WASHINGTON 98507-9649
Fax
(360) 664-2551
VERIFICATION OF AUTHORIZATION TO PRACTICE AND TO OBTAIN AN
ON-SITE WASTEWATER TREATMENT SYSTEM DESIGNER PRACTICE PERMIT
TO BE COMPLETED BY THE AUTHORIZED LOCAL HEALTH JURISDICTION (LHJ)
Please complete this form and either forward to the Board or return to the applicant for Practice Permit
The below named individual is applying for an On-Site Wastewater Treatment Sysytem Designer Practice Permit in accordance
with RCW 18.210.090 and WAC 196-31. State law requires persons applying for this permit to obtain verification from each
local health jurisdiction that they hold a current authorization on or before July 1, 2000 to perform design services and submit
designs to that LHJ. This form will provide the Board with that verification. Please complete and sign where indicated.
Applicant’s Name
Date of Birth
Address
I hereby certify that according to all available records, the above named individual has/had authorization on or before
July 1, 2000 to submit wastewater treatment system designs to __________________________________________
Health District Name
health jurisdiction.
I also attest that I am qualified and authorized to provide this information.
X
Authorized Signature
Date
Printed Name
(stamp, if any)
Administrative services provided by the Department of Licensing which has a policy of providing equal access
to its services. If you need special accommodation, please call (360) 664-1575 or TTY (360) 586-2788.
EN-651-010 O/S DESIGNER APP. (N/6/00)FM Page 3 of 3

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