Environmental Health Services, Safe & Healthy Environments “The Mill” 15 Hopetoun Street, Bendigo PO Box 733, Bendigo Vic 3552 Telephone: 5434 6333 Email:
[email protected] SEPTIC TANK FILE RETRIEVAL REQUEST Application Form PROPERTY ADDRESS: ___________________________________________________________ Age of building _________ Builder name (If known) _______________________________ APPLICANT DETAILS: Current Owner __________________________________________________________ Applicant / Authorised Rep _________________________________________________________ Owner is applicant? Yes £ No £ If NO, is copy of consent attached? Yes £ No £ Signature of Applicant _________________________________ Date _____________________ Contact Ph Nos (Home / work) ________________________ (Mobile) ___________________________ Email address ___________________________________ Fax _______________________ (for the purpose of document delivery) I would like retrieved information emailed to the above address £ I would like retrieved information posted to the above address £ INFORMATION (please tick required boxes) Environmental Health $150.00 Septic Permit Number: (if known) _______________ Lot Number (address): ___________ Septic Permit £ Septic Tank Location £ Other: _________________ £ Notes: __________________________________________________________________________________________ __________________________________________________________________________ “OFFICE USE ONLY” FEE PAID $ _____________ Receipt to: Environmental health: RECEIPT NUMBER _______________________