1031 Cliff Rd - Septic Maintenance Form 2016-05-02 ---------------------
For Office Use
� Date Received: I
no I
city of EaEffn I Staff.
3830 Pilot Knob Road
MAY z ox ?--------------------I
Eagan NIN 55122
Phone: (651)675-5675
Fax: (651)675-5694 r
Email: commdevelopment(dcitvofeaaan.com
SEPTIC SYSTEM MAINTENANCE FORM
Date Pumped: -���P #of Tanks Pumped: 2, Total GWons Pumped: �l V
Site Address: �d f C11 ' d1 pGf G� E�jcty[ /Y?N J /Z3
Owner's Name: ���°u-S �� tV a-,r`/"/et J, A) oreee i
Owner's Address(if different from site):ar7
Maintainer's Name: oll/ e � 21?2q
Private Residence: Commercial: Disposal Location: Jaqj s` �- 2T 6-- f;,P -1, eld-
s�G
Condition of Baffles: d Type of Tanks: C4fl Size of Tanks:ls-&'A4'-0
f o'vv fu 'Y"r
Pumped Through: (4 �OfIL Effluent Sewage Discharge: Yes: No:
Comments: t8 ➢Py+'ns`tt
Please submit completed forms to the Building Inspections Division via mail,fax or email.