955 Cliff Rd - Septic Maintenance Form 2018-07-313830 PILOT KNOB ROAD I EAGAN, MN 55122_1810
(651) 675-5675 1 TDD: (651) 454-8535 1 FAX: (651) 675-5644
buildinginspections citvofea n ill
Date Pumped:
Site Address:
For Office Use I
1 I
II
Date Received: _
I I
staff:
SEPTIC SYSTEM MAINTENANCE FORM
# of Tanks Pumped: Total Gallons Pumped
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Owner's Name 0��� Ic ►� i~iUU���� ��A\2,L ;
Owner's Address (if different from site):
Owner's Email: iI it It��IJI.,*1(S� /�P.R`t C, n^/�►L . Co
Maintainers Name: U ANc
Private Residence: k Commercial:
Condition of Baffles:
Pumped Through:
Comments:
S L- k-p"T I o.wS
Disposal Location:
Type of Tanks:
Owner's Phone #: 3)U
License Number: i3c L IL% T9
Size of Tanks:
Effluent Sewage Discharge: Yes:
No:
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Please submit completed forms to the Building Inspections Division via mail, fax or email.