Septic System Discharge Log Form
Use this form to record details of each septic system discharge event accurately and completely.
Property Identification or Location
*
Date and Time of Discharge
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Discharge Source/Type
*
Please Select
Tank Overflow
Line Break
Pump Failure
Blocked Drain
Other
Estimated Volume Discharged (in gallons or liters)
*
Receiving Area (e.g., lawn, ditch, waterway)
*
Please Select
Lawn
Ditch
Nearby Waterway
Driveway
Other
Observed Condition at Discharge Site
*
Please Select
Standing Water
Odor Present
Visible Solids
No Visible Impact
Other
Weather/Precipitation Context
*
Please Select
Clear/Dry
Rain
Heavy Rain
Snow
Other
Actions Taken
*
Reporter Name and Contact Information
*
Follow-up Needs or Additional Comments
Submit Log
Should be Empty: