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.
•
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