835 Cliff Rd - Septic Maintenance Form 2012-08-02Aug 10 12 08:27a Greg Gudbjartsson 952- 469 -3963 p.3
4 1,! 1/ ' City of Eagan
3830 Pilot Knob Road
Eagan MN 55122
Phone: (651) 675 -5675
Fax: (651) 675 -5694
Email: commdevelopment(c cityofeagan.com
SEPTIC SYSTEM MAINTENANCE FORM
Date Pumped: Z' —Z V i Z— # of Tanks Pumped: l Total Gallons Pumped: r
Site Address:
Owner's Name:
PCL .c.l k
%35 C . c
Owner's Address (if different from site):
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Maintainer's Name: .6. ` f ii`
Private Residence: tv Commercial:
Condition of Baffles: )C
Pumped Through:
Disposal Location:
Type of Tanks:
Effluent Sewage Discharge: Yes:
For Office Use 1
Date Received: Q V ` `? / �
Staff:
License Number: .� t
Size of Tanks:
Please submit completed forms to the Building Inspections Division via mail, fax or email.
i
No: $3