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Septage Hauler Discharge Permit Application

  1. Permit Information
  2. Permits are valid from July 1 through June 30 of the following year.
  3. Permit Application Status:*
  4. Applicant Information
  5. Vehicle / Tank Information
  6. Septage Volume Information:
  7. Certification & Indemnification Agreement
  8. Indemnification Agreement*
    In consideration of being issued a septage hauler discharge permit by the City of Concord ("City"), Permittee agrees to defend, indemnify, and hold harmless the City and its officials, agents, and employees (collectively, the "Indemnified Parties") from and against all demands, claims, suits and actions seeking damages, penalties, attorney's fees, costs, expenses, equitable relief, statutory relief or any other relief on account of bodily injury, death, personal injury, property damage, economic injury and any other injury or loss, (collectively, "Liabilities") arising from or relating to this permit, unless the Indemnified Parties were solely negligent. The indemnification obligations set forth herein shall survive the term of the permit. Permittee must choose defense counsel acceptable to the City and obtain the City's consent to any proposed settlement.
  9. Electronic Signature Agreement*
    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, 3) you are duly authorized to agree to these terms and consent to this electronic submission.
  10. Leave This Blank:

  11. This field is not part of the form submission.