SEPTIC PUMPING ORDER FORM
* Required Fields
* Req. Service Date   
* Customer Name
* Street Address
* City, State, Zip
Township County
*Home Phone Work Phone
* Email
Billing Address
as above
Tax Exempt? If Yes, Exemption Number
Will someone be home?
Payment
Note:  If you choose to pay by Credit Card, someone from our office will contact you for your Credit Card information.

Location Information
Service Location
Age of Home
Nearest Cross Street
Directions/House Description
Tank Locations and Volumes
Tank Lid Exposed? Last time pumped?
Best Approach to Tanks
Extra Hose Needed? (> 100' of Hose):
Experiencing Any Problems?

Service Agreement

By requesting the septic or drain cleaning services, I understand that the nature, location and system condition cannot be determined prior to the actual service.

While normal precautions are taken to prevent property damage, a normal part of the septic service involves the use of a probe to penetrate the earth in search of buried tanks.  It is necessary to position the service truck on the property to service the system depending upon its location.

I acknowledge that damage can result to buried utilities such as sprinkler systems, wiring, water lines, gas lines, fuel lines, fuel storage tanks, paved driveways, lawns, etc. during location and service.  If necessary to cross any unpaved areas of the yard, English Sewage Disposal, Inc. is not responsible for ruts resulting from such passage and release English Sewage Disposal, Inc., its employees and officers from any claim of property damage resulting from the service.

I represent and warrant that I am the owner or the duly authorized agent of the owner(s) of the premises and accept full responsibility.  I represent and affirm that I am of legal age and can contract in my own name.

In the event my account is referred to a collection agency or attorney for non-payment of my balance, I will be responsible for all costs associated with such action.  These will include all attorney fees, court costs, interest on the unpaid balance, collection fees and any other such cost incurred to make English Sewage Disposal, Inc. whole for the work performed.

I personally guarantee payment of the account.  I represent and affirm that I have read this waiver and understand and consent to its terms.

By clicking the "Submit" button below, I agree to this Service Agreement.

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