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4555 Acorn St - Septic Maintenance Form 2012-09-20City of 3830 Pilot Knob R Eagan MN 55122 Phone: (651) 675 -5 Fax: (651) 675 -569 Email: commdevel Date Pumped: i "'�� Site Address: Owner's Name: (2,0.0s1/44 Eaaall • ad 76 pmentOcityofeagan.com For Office Use G Date Received: It 0 IS / SEPTIC SYSTEM MAINTENANCE FORM 1 # of Tanks Pumped: Total Gallons Pumped: 4L' 0(P\ 5�T n•-h-e 2hea\ � Owner's Address Of different Maintainer's Name: fl) Private Residence: Condition of Baffles: Pumped Through: Comments: om site): jj O Commercial: License Number: 2 /C1 Disposal Location: 3 5 +. f &AA. WT 6n-0 • Type of Tanks: ,_.) & Size of Tanks: S-C>D Effluent Sewage Discharge: Yes: Please subm completed forms to the Building Inspections Division via mail, fax or email. • le