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Septic Tank Pumping / Maintenance <br />Owner Information <br />Date: _TI 1Zru z3 DELIVERED MAY 2 8 2023 <br />Owner: O-sS 1-7a tv a v� Phoney: �S2 `cL�' � <br />Proper- address: Owners address: (if different) <br />Z. �f O 0 �a.� S�c-� � <br />_f�rot �� mi✓ �S,3y/ <br />Reason for Pumping: <br />Method of access: <br />Condition of tanks: <br />filter cleaned: es <br />qq'o <br />n/a <br />Tank leakage observed: <br />iallons removed: <br />1 13.qU 42 /U u <br />Disposal method: <br />Safety concerns: <br />Recommended repairs: <br />/1&1 t <br />Tank Information <br />compliance inspection 0 holding tank EL-mantenance <br />07 manholes ❑ inspection pipe (holding tanks only) <br />(owner signature req'd if refusing to allow pumping through In <br />aintenarce bolt) <br />baffles good: alarm working: YY� <br /><=-0'S-> <br />NO <br />n/a n/a <br />above operating depth: Yes o (repairs recommended) <br />below operating depth: Yes : o (failing to protect groundwater) <br />#3 <br />#4 <br />pump tank <br />%'t total 3 <br />municipal <br />`✓� <br />location:zt7C <br />I <br />and apply ❑ <br />location: <br />1 hereby cent fy that I have completed this work in accof•dance with J14N 7083.0770 and ant? local requirements. <br />tYo enntu7 ' a or guarantee offirtnre s}°stem performance has been nor can be made. <br />Chip's Septic Service. LLC SSTS License <br />Maintainer signature 16762 Babcock Avenue 42064 <br />Lester Prairie, MN. 55354 <br />(952) 200-3176 <br />