863 Lakewood Hills Rd - Septic Maintenance Form 2022-10-28---------------------
For Office Use I
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Date Received: I
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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.