915 Lakewood Hills Rd - Septic Maintenance Form 2025-10-08HENNES SEPTIC PUMPING, LLC
952-403-0058
Individual Sewage Treatment System (ISTS) Pumping record
Ares
Owner ��� kivdok Address
Y
Pumper jk—rw No. of Tanks Pumped Total Gallons Pumped 31W 1W
Check all that apply -„Residential ❑ Commercial Mental
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Septic L3Holding L3Pump Chamber LlCesspool L3Abandoned L3 other:
❑ e laced Baffles
Condition of Baffles (baffles must be inspected) I Acceptable LlUnacceptable R P
Reason for pumping? Water tight tank? Yes ❑ No
Disposal Location (be specific)
Any tank leakage below or above the operating depth? - Cl Yes JkNo
Pumped From: ElMaintenance Hole ❑ Removed Tank Lid (staves for example) I 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 Ma' nance Hale / Tank Lid to enable the removal of solids.
Signature o Owner/ Owner's Agent Reason for not pumping through the Maintenance Hole /Tank Lid
Safety Concerns / Repairs
Pumper / Inspector Signature .
Date 0 14-1
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.