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863 Lakewood Hills Rd - Septic Maintenance Form 2022-10-28--------------------- For Office Use I I I I Date Received: I I I I I I Staff: ---------------------I SEPTIC SYSTEM MAINTENANCE FORM Date Pumped: �( 12b I T;z— # of Tanks Pumped: I Total Gallons Pumped: 15 -Da Site Address: lb l9 �j~ L-4 J f? Owner's Name: 1a1 L" Owner's Address (if different from site): Maintainer's Name: Private Residence: V_ Commercial: Disposal Location: V-1 M I V License Number: ,2� 9R Condition of Baffles: _ 4U Ld Type of Tanks: LPV�✓i"►M4-,.r. Size of Tanks: � Pumped Through: VO l AA,-) hvl 0 Effluent Sewage Discharge: Yes: No: Comments: Please submit completed forms to the Building Inspections Division via mail, fax or email.