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Septic Tank Pumping/Maintenance <br />Owner Information <br />--=f--= <br />Phone: <br />Owner: Let<'7 <br />�er <br />Email: <br />i <br />Property Address: 4`(C> d0 <br />eSfre�:f <br />Owner's Address <br />(if different) <br />Tank Information <br />Reason for Pumping: <br />❑ Complinace Inspection <br />❑ Holding Tank <br />Q-I'viaintenance <br />Method of Access: <br />D<anholes <br />❑ Inspection Pipe <br />(holding tanks only) <br />Condition of Tanks: <br />(Owner's signature req'd if refusing to allow pumping <br />through maintenance hole) <br />Filter Cleaned <br />Yes Baffles good: <br />es <br />Alarm working: Y D <br />No <br />No <br />N/A <br />N/A <br />N/A <br />Tank Leakage Observed: Above operating depth <br />Below operting depth <br />Gallons Removed: <br />#1 l00 U #2 !DO U #3 #4 <br />Disposal Method: Municipal: Q <br />Land Applied: ❑ <br />Safety Concerns: n 607e- <br />Recommended Repairs: h on <br />Comments: <br />Yes/c)(repairs recommended) <br />Yes/I�f>� failing to protect groundwater) <br />tank <br />Total Z SW <br />Location: Watertown Wastewater Facil <br />Location: <br />I hereby certify that I have completed this work in accordance with MN 7083.0770 and any local requirements. <br />No determination or guarantee offuture sy1:7 <br />e has been nor can be made. <br />Chip's Septic Service, LLC & SSTS <br />r--irtzer's Sewer Services --7License <br />. _ , 62 Babcock Avenue Maintaner Signature #2064 <br />Lester Prairie, MN. 55354 <br />(952) 200-3176 <br />chipseptic �r��inail cone <br />revised 312025 <br />