Updated 6/20/19
Septic System Pumping
and Assessment Report
Owner(s) Names
Septic system less than two years old? No Yes - stop and mail form
Date Assessed
Date Installed (if known)
Number of Tanks & Capacity
Type of System
Gallons Removed
Tanks have manholes Covers
Yes or No
System is Watertight
Yes or No
System Pumped Regularly
Yes or No
Frequency Recommended
Inlet and Outlet Baffles Answer Yes or No
Yes or No
Problems Detected
Yes or No
Explanation of Problems Detected
(if applicable)
Baffles Replaced
Yes or No
Are there signs of overflow or effluent percolating from the ground or sewage
backup in the home?
If yes, explain:
The undersigned certifies that the above information is correct to the best of their
Company Information
Company Name
Licensed Pumpers Name
MPCA License Number
Phone Number
Return to:
e: city@medinamn.gov
f: 763-473-9359
m: 2052 County Rd 24,
Medina, MN 55340