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1055 Cliff Rd - Septic Maintenance Form 2012-08-29Feb 22 2016 09:31AM LaRoches 5073344692 page i I 4ph� . 4X City of Ea jan 383D Pilot Knob Road Fagan MN 55122 Phone: (651) 675-5675 Fax; (651)675.5694 Email: commdeveloomentP-cityofeaasn.com --------------- For Office Use i f I I �o Ilp a�t� Rcoe�ved: I I I Staff: _� 1 L-------------------� 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.