870 Lakewood Hills Rd - Septic Maintenance Form 2025-10-14 (2)HENNES SEPTIC PUMPING, LLC
Individual Sewage Treatment System (ISTS) Pumping Record 952-403-0058
Owner .tr Address 0'
Pumper No. of Tanks Pumped Total Gallons Pumped �.
Check all that apply: i Fjkesidential ❑ Commercial ❑Rental
jq-'S'eptic C7 Holding' ❑ Pump Chamber ❑ Cesspool ❑ Abandoned ❑ Other:
Condition of Baffles (baffles must be inspected) 4Acceptable ❑ Unacceptable ❑Replaced Baffles
Reason for pumping? I L) 0 Water tight tank? 11-Yes ❑ No
Disposal Location (be specific) Any tank leakage below or above the operating depth? - ❑ 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.
Nt
Signature of Owner/ Owner's Agent Reason for not pumping through the Maintenance Hole/ Tank Lid
Safety Concerns / Repairs
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. Submit a: permit whenever
a tank is pumped for abandonment. Pumping the tank does not constitute a compliance inspection.