835 Cliff Rd - Septic Maintenance Form 2016-06-01 ---------------------
For Office Use
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I Date Received: .J I
an
City of I Staff:
EandH
3830 Pilot Knob Road
Eagan MN 55122
Phone: (651)675-5675
Fax:(651)676.6694
Email: commdevelopment(&cityofeagan.com
SEPTIC SYSTEM MAINTENANCE FORM
Date Pumped: e�;,' 'f—,PO/ � #of Tanks Pumped: Total Gallons Pumped: l U y j
Site Address: �7>-5— GG) a
Owner's Name: PA ) A- 0UL'`i1SK
Owner's Address(If different from site):
License Number;Maintainer's Name: I .Y— 2
Private Residence: Commercial: Disposal Location:
Condition of Baffles: O �� Type of Tanks: E(=L'T, Size of Tanks: /LD W
Pumped Through: i/ .t Effluent Sewage Discharge: Yes: No: ^
Comments:
Please submit completed forms to the Building Inspections Division via mail,fax or email.