3575 Argenta Tr - Septic Maintenance Form 2014-01-13 ---------------------
For Office Use 2q Date Received: L2-ol(,'
City of Eli (in i Staff:
3830 Pilot Knob Road
Eagan MN 55922
Phone: (651)675-5675
Fax: (651)675-5694
Email: commdeveloomentC&citvofeaaan.com
SEPTIC SYSTEM MAINTENANCE FORM.
Date Pumped: ` #of Tanks Pumped: Total Gallons Pumped:
Site Address:
A
Owner's Name:
Owner's Address(if different from s'e):
Maintainer's Name: License Number:
Private Residence: commercial: Disposal Location:
Condition of Baffles: ���� Type of Tanks: Size of Tanks:
Pumped_ Through: Effluent Sewage Discharge: Yes: No:
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SOLD BY DATE — } ;
Ing Inspections Division via mail,fax or email.
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ADDRESS
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CASH C.O.D. CHARGE ON ACCT:
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RECEIVED By -
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---------------------
I For Office Use
RECEIVF-
I A I
I Date Received: y I
JUL J21017 1 i
City of EaV� I
I Staff: I
---------------------
3830 Pilot Knob Road
Eagan MN 55122
Phone: (651) 675-5675
Fax: (651) 675-5694
Email: commdevelopment(a)cityofeagan.com
SEPTIC SYSTEM MAINTENANCE FORM
Date Pumped: #of Tanks Pumped: Total Gallons Pumped: /4-00
Site Address:
e
Owner's Name:
Owner's Address(if different from site):
Maintainer's Name: —Ll License Number:
Private Residence: Commercial: Disposal Location:
Condition of Baffles: � Type of Tanks: Size of Tanks:
i
Pumped Through: Effluent Sewage Discharge: Yes: No:
Comments:
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AAILaA -IM d,- �e��� �r4u�d, ivy VLe. i s Co �►
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Please submit completed forms to the Building Inspections Division via mail,fax or email.