If less than 25% of septic tank connected with soak pit, provide

document of action plan that proofs that ULB is planning to install soak
pits within a year
I …………………………………………………………........................................ (Name),
Executive Officer of ……….…………………...………………………….
….......................................................... (Name of ULB) do hereby submit the
action plan that ULB is planning to install soak-pits within a year:
1. Field visit by ULB Official to identify ward-wise households with septic
tanks not connected to soak-pit.
2. Ward-wise orientation program to inform the households to connect their
septic tanks to soak-pit as per IS-2470
3. Individual household visit by SS informing connecting their septic tank to a
soak pit
4. Notice to household to connect their septic tank to a soak pit
5. Circulating monthly construction plan to ensure timely completion
6. Sharing few contractors’ details to households for construction purpose.
7. Ward-wise monthly progress report verification.
8. Defaulters to be fined
9. ULB using own-funds/CSR/others for soak-pit construction purpose
10.IEC Awareness on mandatory soak-pit construction.

……………………………………………….…………………….…
(Signature and Name of assigned nodal ULB Official

……………………………………………….…………………….…
(Signature and Name of Executive Officer)

ULB Name-
Date-
Contact/Phone number:
(Attach copy of inspection report, details of complete ward-wise households
with/without septic tank connected to soak pit/progress plan report)
Document for scheduled inspection of septic tank with soak pit
I …………………………………………………………........................................ (Name),
Executive Officer of......... (Name of ULB) do hereby declare that:
a) Scheduled on-field inspection of septic tank with soak pit is carried out by
assigned nodal ULB Official (…………………………………. (Name & Designation))
b) The inspection is carried out every…………. (month/quarter/year)
c)The area covered is the within the ULB boundary.
d)The information submitted (attached detail document stating number of
households with proper septic tank connected to a soak-pit ward-wise) is correct
to the best of my knowledge

……………………………………………….…………………….…
(Signature and Name of assigned nodal ULB Official

……………………………………………….…………………….…
(Signature and Name of Executive Officer)

ULB Name-
Date-
Contact/Phone number:
(Attach copy of inspection report, details of complete ward-wise households
with/without septic tank connected to soak pit)
Document for Septic tank to confirm the design is as per IS: 2470 Part-I
I …………………………………………………………........................................ (Name),
Executive Officer of ……….…………………...………………………….
….......................................................... (Name of ULB) do hereby declare that:
a) The septic tanks present are designed as per IS: 2470 part-I
b) Field verifications was done by nodal ULB Official (………………………………….
(Name & Designation)
c) The verification is carried out every…………. (month/quarter/year)
d)The area covered is the within the ULB boundary.
e) The information submitted (attached detail document stating ward-wise
number of households with septic tank designed as per IS:2470 part-I) is correct
to the best of my knowledge

……………………………………………….…………………….…
(Signature and Name of assigned nodal ULB Official

……………………………………………….…………………….…
(Signature and Name of Executive Officer)

ULB Name-
Date-
Contact/Phone number:
(Attach copy of inspection report, details of complete ward-wise households
with/without septic tank designed as per IS: 2470 part-I)
Document for Septic tank to confirm the design is as per IS: 2470 Part -
II
I …………………………………………………………........................................ (Name),
Executive Officer of ……….…………………...………………………….
….......................................................... (Name of ULB) do hereby declare that:
a) The septic tanks present are designed as per IS: 2470 Part-II
b) Field verifications was done by nodal ULB Official (………………………………….
(Name & Designation)
c) The verification is carried out every…………. (month/quarter/year)
d)The area covered is the within the ULB boundary.
e) The information submitted (attached detail document stating ward-wise
number of households with septic tank designed as per IS:2470) is correct to the
best of my knowledge

……………………………………………….…………………….…
(Signature and Name of assigned nodal ULB Official

……………………………………………….…………………….…
(Signature and Name of Executive Officer)

ULB Name-
Date-
Contact/Phone number:
(Attach copy of inspection report, details of complete ward-wise households
with/without septic tank designed as per IS: 2470 part-II)
Document for new Septic tank to confirm the design is as per IS: 2470
I …………………………………………………………........................................ (Name),
Executive Officer of ……….…………………...………………………….
….......................................................... (Name of ULB) do hereby declare that:
a) The new septic tanks present or constructed are designed as per IS: 2470
b) Field verifications was done by nodal ULB Official (………………………………….
(Name & Designation)
c) The verification is carried out every…………. (month/quarter/year)
d)The area covered is the within the ULB boundary.
e) The information submitted (attached detail document stating ward-wise
number of households with new septic tank designed as per IS:2470) is correct to
the best of my knowledge

……………………………………………….…………………….…
(Signature and Name of assigned nodal ULB Official

……………………………………………….…………………….…
(Signature and Name of Executive Officer)

ULB Name-
Date-
Contact/Phone number:
(Attach copy of inspection report, details of complete ward-wise households
with/without new septic tank designed as per IS: 2470)
BASIC-FORMAT

SL Wa Holdi Septic- Soak Desig Inspec Acti Progr Rema

NO rd ng- Tank(Y - ned ted By on ess rks
No No /N) pit(Y/ as per Plan
N) (IS /
2470/I stat
S us
2470
part-
I/IS
2470
part-II

 Geo-tagged septic tanks with soak pits- On-going survey form

 Document of proofing geotagged of septic tanks with soak pits-
On-going survey form
 Document of Minimum 25% septic tanks that have been cleaned in
the year of application for ODF++- Log book preparation
 By-laws stating cleaning of septic tanks carried out in every 3
years-FSSM Regulation
 Logbook of cleaning of septic tanks-Log book
 Ward-wise list of registered and licensed private desludging
operators- ULB Cesspool and Registered PVT Vehicle for ULB boundary
operation (prepare ward wise if required)
 5. FORMAT FOR SELF-DECLARATION TO BE SUBMITTED
BY DESLUDGING OPERATORS
I …………………………………………………………........................................ (Name),

Director / equivalent of ……….…………………...…………………………..(Name and

registered address of desludging entity) operating in

….......................................................... (Name of ULB / development authority /

cantonment board) do hereby declare that we:

a) Are registered with and licensed by ULB/ Development Authority / Cantonment

Board.

b) Are contracted by the ULB / Development Authority /Cantonment Board to

provide sludge/septage emptying services to households or community and/or
public toilets (copy of contract agreement and details of households and/ or
community/public toilets allotted by ULB/ Development Authority / Cantonment
Board for providing services to, both in annexure).

c) Utilise mechanised equipment to provide emptying services

d) Use personal protective equipment (PPE) to provide mechanical emptying

services.

e) Transport the emptied faecal sludge and septage to nearby faecal sludge
treatment plant (FSTP) / sewage treatment plant (STP) with co-treatment
facility / solid waste management (SWM) treatment plant with co-treatment
facility (tick whichever applicable) (details of treatment facility in annexure)
which is operated as per Central Pollution Control Board (CPCB) norms or as per
amended norms by state PCB.

f) Do not dump untreated faecal sludge in the open environment—water bodies,

drains, open land, etc.

……………………………………………….…………………….…

(Signature and Name of Director or equivalent of desludging operator)

Registered office address:

Phone number:
Date:
(Attach copy of contract agreement, details of households and/ or
community/public toilets allotted by ULB/ Development Authority / Cantonment
Board for providing services to, and details of treatment facility where faecal
sludge/septage is being conveyed to)
 DECLARATION FOR REGISTERED WORKFORCE

I (Name of EO) hereby confirm that following numbers of septic tank cleaners are
registered with (Name of ULB) only. I also assure that these personnel are
trained regularly on quarterly/half-yearly basis to get maximum output and
quality. All of the registered workforce is allowed to clean septic tanks only with
use of proper personal protective equipment.

Seria Name of Driver/Helper Designation

l No.
1.
2.
3.
4.
5.

Name of Executive Officer:

Signature:
Date:
 DECLARATION FOR REGISTERED SEPTIC TANK CLEANERS

I (Name of EO) hereby confirm that following numbers of Septic tank cleaners
and operators are registered with (Name of ULB) only. These operators and
cleaners have been disposing sludge at the Septage Treatment Plant/DRE and
their vehicle movement is monitored by the Nodal Officer through GPS tracking.

Seria Name of Operator Private/ULB

l No.
1.
2.
3.
4.
5.

Name of Executive Officer:

Signature:
Date:
Declaration for reuse of treated Waste water from Septage Treatment
Plant
I …………………………………………………………........................................ (Name),
Executive Officer of ……….…………………...………………………….
….......................................................... (Name of ULB) do hereby declare that the
treated waste water from the Septage Treatment Plant at (Location) is used for
gardening purposes within the premises of the Treatment plant to reduce the
usage of fresh water.

……………………………………………….…………………….…
(Signature and Name of assigned nodal ULB Official

……………………………………………….…………………….…
(Signature and Name of Executive Officer)

ULB Name-
Date-
Contact/Phone number:
 DECLARATION FOR SUSTAINABLE FINANCE MECHANISM

I,….........., Executive Officer of (Name of ULB) do hereby declare that (ULB Name)
has no sustainable financing mechanism i.e. operational expenditure of FSSM
value chain is not getting recovered from the revenue generated from advance
remittance of user charges.
Operation & Maintenance cost (INR) Revenue Generated (INR)

……………………………………………………..... (Signature, and Name of

Chairperson / Executive Officer)
Date:
Seal: