Fillable Pumper Agreement Form (Minnesota Department of Revenue)

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Pumper Agreement Form (Minnesota Department of Revenue)

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Property Owner:
Parcel ID: Phone Number:
Property Address:
Mailing Address (if different):
Legal Description (from deed/abstract):
Township: Section:
SSTS Permit #: Operating Permit #:
Permit/Parcel/Owner Information:
StearnS County environmental ServiCeS
SubSurfaCe Sewage treatment SyStem
Ht monitoring and diSpoSal ContraCt
705 Courthouse Square Administrative Center Rm 343
St. Cloud, Minnesota 56303 (320) 656-3613 or 1-800-450-0852
The above referenced property contains a Sewage Tank for the disposal of sewage and/or non-domestic wastes that are
generated on site. This serves as an agreement, entered into by and between a MPCA licensed maintenance business and the
property owner to retain pumping services on a regular scheduled basis as determined by the management plan and or
operating permit established for this SSTS.
Holding Tank Maintenance Agreement
The property owner is required to retain the maintenance services in order to provided for the proper disposal of sewage and/or
non-domestic waste to protect the environment and public health. The maintenance of the sewage tank shall occur on a regular
basis to prevent sewage discharge to the ground surface and/or backup into the dwelling or Other Establishment. By January 31
st
of each year, the property owner shall submit maintenance records for the previous year to Stearns County Environmental
Services at 705 Courthouse Square, St. Cloud, MN 56303.
A copy of a written agreement between the property owner and the maintenance business shall be submitted to the local unit of
government with jurisdiction. The MPCA licensed maintenance business agrees to properly dispose of sewage/non-domestic
wastes in accordance with Minnesota Rules 7080 and all other applicable Minnesota Rules. Failure to have your system
maintained according to this agreement may result in an enforcement action by Stearns County.
Maintenance Business:
License #:
Date:
Signature of Property Owner:
Phone number:
Date:
Signature of Maintainer:
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Pumper Agreement Form (Minnesota Department of Revenue)

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Completed 18 July 2020

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