1035 Cliff Rd - Septic Maintenance Form 2022-04-07Cit Y � of Ea an
3830 Pilot Knob Road
Eagan MN 55122
Phone: (651) 675-5675
Fax: (651) 675-5694
Email: commdevelopment(a-cityofeagan.com
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For Office Use
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I Date Received:
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I Staff:
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SEPTIC SYSTEM MAINTENANCE FORM
Date Pumped: # of Tanks Pumped: Total Gallons Pumped: k5oc3
Site Address:
Owner's Name: 1 V l t S1e- CL
Owner's Address (if different from site):
(� 1
Maintainer's Name: \—G• KO Ck� S License Number: D o d
Private Residence:_ Commercial: Disposal Location: � ��Y'M�N\�
Condition of Baffles: ��c�s�1�. — \Y�L� Type of Tanks: S,--p-i, L Size of Tanks:
Pumped Through:
Comments:
Effluent Sewage Discharge: Yes: No: X
C -o rn�c3�t}w�e,n�4- 1 Scu ry `-`1 `i
Ott 3"
Please submit completed forms to the Building Inspections Division via mail, fax or email.