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Septic Tank Maintenance Agreement

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PLEASE RETURN COMPLETED FORM TO:

POLK COUNTY ZONING

GOVERNMENT CENTER

100 POLK COUNTY PLAZA, SUITE 130

Erase Form

Print Form

BALSAM LAKE, WI 54810

PHONE:(715) 485-9111

SEPTIC TANK MAINTENANCE AGREEMENT

OWNER/BUYER____________________________________________________________________

MAILING ADDRESS_________________________________________________________________

SEE TAX RECEIPT

to complete legal description:

Parcel # __ __ __ - __ __ __ __ __ -__ __ __ __

Property located in the _____1/4 _____1/4, Section _____, T _____N, R _____W,

Town of ___________________________, Lot _____, Subdivision/Plat ______________________

Property Address (house number & road name) _______________________________________

Improper use and maintenance of your septic system could result in its premature failure to handle wastes.

Proper use and maintenance should extend the life of the system considerably. Proper maintenance

consists of pumping out the septic tank every 2-3 years or as needed by a licensed septic tank pumper.

What you put into the system can affect the function of the septic tank as a treatment stage in the waste

disposal system. Avoid allowing the following substances to enter your sanitary system.

Clear water from sump pumps

Grease

Chemicals - lye, acids, etc...

Disposable diapers

Paper other than toilet tissue

Cigarette butts

Sanitary napkins/tampons

10. Fabrics

Garbage from grinders

11. Garbage

Septic tank cleaners

12. Drain oil

COST-SHARING: Polk County residents may be eligible to receive some cost- share funding for the

replacement of failing systems whereby such systems were in operation prior to July 1, 1978. In providing

any cost sharing, the state requires that owners of all new systems agree to keep their systems properly

maintained. Naturally, the proper maintenance is beneficial to you and the general public.

The property owner agrees to submit to the county a certification form (to be provided by the county) every

3 years -- signed by the owner and by a master plumber, journeyman plumber, restricted plumber, or a

licensed septage hauler. The form shall require certification of the following.

That the on-site wastewater disposal system is in proper operating condition.

That after inspection and after pumping (if necessary), the septic tank is less than 1/3 full of

sludge and scum.

I, the undersigned, have read the above requirements and I agree to maintain the private sewage disposal

system in accordance with the standards set forth, herein, as set by the State of Wisconsin.

Signature

SIGNED

DATE____________________________

SepticMaintenanceAgreement 8/20/2014

Septic Tank Maintenance Agreement

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