870 Lakewood Hills Rd - Septic Maintenance Form 2025-10-143830 PILOT KNOB ROAD I EA AN, MN 55122-1810
(651) 675-56751 buildinginst)ections 0eaganinngov
Date Pumped:
# of Tanks Pumped:
Site Address: I -112z:5 /ex
Owner's Name:
---------------------
For Office Use
I
Date Received: I
I I
I I
I staff: I
I— — — — — — — — — --- — — — — I
Total Gallons
Pumped:
Owner's Address (if different from site): �Fave--
Ownees, Email: A.5 � , C 0/f Owners Phone
KS -1
Maintainer's Namw. License Number:
Private Residence: Commercial: Disposal Location:
Condition of Baffles:
Comments:
Type of Tanks:
Size of Tanks:
Effluent Sewage Discharge: Yes: No:
Name of Person Completing Form: Date'.
You maysubscribe to receive an electronic notification from the City of proposed ordinances by signing up for an email update
on the City's website at c&2h2jjan.RomJsubscribe.
Please submit completed forms to the Building Inspections Dhftion via mail or email.
HENNES SEPTIC PUMPING, LLC- r,com
Individual Sewage Treatment System (ISTS) Pumping Record 952-403-0058
Owner :� `�` �_ ,�� a r Address �''� � E�_ .. a)':^�a ��. (Z i) i) `�
Pumper No. of Tanks Pumped Total Gallons Pumped
Check all that apply: 0 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
Disposal Location (be specific)
Any tank leakage below or above the operating depth? - Ll Yes -❑ No
Pumped From: ❑ Maintenance Hole ❑ Removed Tank Lid (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
Safety Concerns / Repairs
Reason for not pumping through the Maintenance Hole/ Tank Lid
Pumper / Inspector Signature Date
Only one permit is needed per ISTS. If there is more than one ISTS on a property, submit a separate permit for each ISTS. Subunit a permit whenever
a tank is pumped for abandonment. Pumping the tank does not constitute a compliance inspection.