1244 Deerwood Dr - Septic Maintenance Form 2012-07-11Aug 10 12 08:27a Greg Gudbjartsson 952- 469 -3963 p.2
4P lifr City of Ea�all
3830 Pilot Knob Road
Eagan MN 55122
Phone: (651) 675 -5675
Fax: (651) 675 -5694
Email: commdevelopment (c� cityofeagan.com
For Office Use
Date Received:
Staff:
SEPTIC SYSTEM MAINTENANCE FORM
Owner's Address (if different from site):
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Maintainer's Name: (U
� G` License Number:
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Private Residence: V Commercial: Disposal Location:
Condition of Baffles: CO 1 Type of Tanks: l TY y
Pumped Through: I' b \ i;L 4 t.e
Comments:
Date Pumped: 7 2— # of Tanks Pumped: I Total Gallons Pumped: Z O C G%
Site Address: t -ft-1 k b'eX2(' 6eia - l`iV"E
Owner's Name: E 1 d k 6 ` --,01- )4
Size of Tanks: ' .k1-@3
Effluent Sewage Discharge: Yes: No:
Please submit completed forms to the Building Inspections Division via mail, fax or email.
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