1055 Cliff Rd - Septic Maintenance Form 2012-08-29Feb 22 2016 09:31AM LaRoches 5073344692 page i
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4X City of Ea jan
383D Pilot Knob Road
Fagan MN 55122
Phone: (651) 675-5675
Fax; (651)675.5694
Email: commdeveloomentP-cityofeaasn.com
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For Office Use i
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SEPTIC SYSTEM MAINTENANCE FORM
Date Pumped: Ok - a — 1(a # of Tanks Pumped: Total Gallons Pumped: WO o
Site Address: - _Ui -4 'Ro "��9 �1 _�� _.--• ---•-
Owner's Name:�[�nK
Owner's Address (if different from site):
Maintainer's Name: License Number;
Private Residence: Y, Commercial: Disposal Location:
Condition of Baffles: C O%,LX.. VvzN— *a- Type of Tanks: <-OnCJLa Slze of Tanks:
Pumped Through: L.30L
\y\6Effluent Sewage Discharge: Yes: No:
Comments:
Please submit completed forms to the Building Inspections Division via mail, fax or email.