1007 Cliff Rd - Septic Maintenance Form 2012-08-27
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I Date Receive ~ ~ I d. "
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3830PiIotKnobRoad ~_~~r_~~~r_~~~_~~ ^~r
Eagan MN 55~2Z Phone: ~65~ ~ 67'55675
Fax: ~65~ ~ 6755694
Email: cammdevelopment(a,cltyofeagan~com ■ it I i i ~ii.~~i~ tl~nnniin~i.~ Ill~.~wlwe
SEPTIC SYSTEM MAINTENANCE FARM
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Date Pumped: w,. # o , ks Pumped: Total Gallons Pum ed; p I ~ esq.
Site Address; ~
Owner's Name; ~
owner's Address cif different from site};
1„'~ ` 1 ~ r r ~ ern ~ 4 Maintainer's Name; license Number:
Private Residence: Commercial; Disposal location: ~ ~
Condition of Baffles; Type of Tanks; Size of Tanlcs:
Pumped Through, Effluent Sewage Discharge; Yes; No;
Comments;
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Please submit completed forms to the Building Inspections Division via mail, fax or email.