1760 Cliff Rd - Septic Maintenance Form 2012-07-25City of Eagan
3830 Pilot Knob Road
Eagan MN 55122
Phone: (651) 675 -5675
Fax: (651) 675 -5694
Email: commdevelopment (c�cityofeagan.com
Date Pumped:
Site Address:
Owner's Name:
A z_
# of Tanks Pumped:
JAIL, 2 t 72012
For Office Use
Date Received:
Staff:
SEPTIC SYSTEM MAINTENANCE FORM
Total Gallons Pumped: /--.
Owner's Address (if different from site):
Maintainer's Name: ( fig .5%,1,0E f2- :5t(' c� t e-ez- License Number: ?1,5
Private Residence: > Commercial: Disposal Location: a + , P4'-LC /
Condition of Baffles: 00 Ce Type of Tanks: Size of Tanks: /5 b C
Pumped Through: VY \A n Ile)) e Effluent Sewage Discharge: Yes: No:
Comments:
Please submit completed forms to the Building Inspections Division via mail, fax or email.