1007 Cliff Rd - Septic Maintenance Form 2016-05-26 ---------------------
For Office Use
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Date Received: (0
f q c�n City of EQ Ql! RECEIVED I Staff:
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3830 Pilot Knob Road MAY 31 2016
Eagan MN 55122
Phone: (651) 675-5675
Fax: (651)675-5694
Email: commdevelopment(cDcityofeagan.com
SEPTIC SYSTEM MAINTENANCE FORM
Date Pumped: //4> it of T Pumped: ! Total Gallons Pumped:
Site Address: d� / ,(Dj
Owner's Name:
Owner's Address(if different from site): t9 r, � L�� 42
Maintainer's Name: License Number:
Private Residence: ir� Commercial: Disposal Location:
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Condition of Baffles: Type of Tanks: S Size of Tanks:
Pumped Through: Effluent Sewage Discharge: Yes: No:�
Comments:
Please submit completed forms to the Building Inspections Division via mail, fax or email.