925 Cliff Rd - Septic Maintenance Form 2015-04-28 � `• I r� I
For ow"Use
.L > Dale Remiwd• o[
City of Eajan
'---------------------1
3830 Pilot Knob Road
Eagan MN 55922
Phone: (651)6175-6675
Fax-.(659)GT64%94
Email:c±oit'-endev..trlopmen#&dyoleanim.Corn
SEPTIC SYSTEM MAINTENANCE FORM
Dale Pumped,. �� It of Tanks Pumped: Total Gallons Pumped:
Site Address:
Owneft Name.,
owner's Address(it dWmrit from sibs).
Maintainer's Name: f � '� License Number:
Private Residence: Commercial,. _ Disposal Location:
CondWon of Baffles- _�; 'type of Tanks: � Size of Tanks:
Pumped Through: ��� Effluent Sewage Discharge: Yes _ ----_- No_
Gominefft
Please submit completed farms to the Building Inspections DiAsion via mail,fax or ernaill.