888 Lakewood Hills Rd - Septic Maintenance Form 2023-07-03HENNES SEPTIC PUMPING
2237 Valley View Rd.
Shakopee, Minnesota 55379
(952) 403-0058
CUSTOMER ORDER NO.
NAME
ADDRESS
DATE
SOLD BY
CASH C.O.D. CHARGE
ON ACCT. MDSE. RET'D.
PAID OUT
QTY.
DESCRIPTIONAMOUNT
Pump Septic Tank
Permit Fee
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Disposal Fee
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_
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15%Servire Charge, Plus $25 Per Month Late Fee, Customer Shall Pay Any Collection Charges Or Other Expenses Including Beasonahle
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Attorney fees Occurred By Hennes Septic Pumping To Collect Amount Due Under This Agreement to Include Lien Against Property.
,
RECEIVED BY
TOTAL
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17909 All claims and returned goods MUST be accompanied by this bill. THANK YOU
HENNES SEPTIC PUMPING, LLC john@hennesseptic.cor-q
Individual Sewage Treatment System (ISTS) Pumping Record 952-403-0058
Owner Address �e r.. 1rC I_( ( 04 k.,
Pumper No. of Tanks Pumped Total Gallons Pumped
Check all that apply: ❑ Residential ❑ Commercial ❑Rental
❑ Septic ❑ Holding ❑ Pump Chamber ❑ Cesspool ❑ Abandoned ❑ Other:
Condition of Baffles (baffles must be inspected) ❑ Acceptable ❑ Unacceptable ❑Replaced Baffles
Reason for pumping? Water tight tank? ❑ Yes ❑ No
Disnosal Location (he sneciflc)
Any tank leakage below or above the operating depth? -❑ Yes ❑ No
Pumped From: ❑ Maintenance Hole ❑ Removed Tank lad (stave, for example) ❑ Inspection Pipe (see below)
I have been informed about the correct tank cleaning procedures and understand that I risk having my system fail prematurely if the tank is not
pumped through the Maintenance Hole / Tank Lid to enable the removal of solids.
Signature of Owner / Owner's Agent Reason for not pumping through the Maintenance Hole / Tank Lid
Safety Concerns / Repairs
Pumper / Inspector Signature
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Data 7/.. ' .-I--
Only one permit is needed per ISTS. If there is more than one ISTS on a property, submit a separate permit for each ISTS. Submit a permit whenever
a tank is pumped for abandonment. Pumping the tank does not constitute a compliance inspection.