1244 Deerwood Dr - Septic Maintenance Form 2016-04-06 ---------------------
For Office Use
Date Received: I
City of Ealn I _____ I
Ed i Staff
---------------I
3830 Pilot Knob Road
Eagan MN 55122
Phone: (651) 675-5675
Fax: (651)675-5694
Email: commdevelopment(a)cityofeagan.com
SEPTIC SYSTEM MAINTENANCE FORM
Date Pumped: — [ , #`o_f�Tanks Pumped: tJ Total Gallons Pumped: 1 5
Site Address: [c�(,' lw �i c. n>_ ,t I I IV---e_
Owner's Name: C>lu J YU
Owner's Address(if different tffrom tsite):
Maintainer's Name License Number:
Private Residence: jam'/ Commercial: Disposal Location: ,.,�r v,4L
Condition of Baffles: Type of Tanks: n:? yr L v- Size of Tanks: 1 SQL t a
n
Pumped Through: D l�7i vi LJ 4� 7 y Effluent Sewage Discharge: Yes: No: X
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Comments: � 4� C �-wtc>, l <u �� l vlG K w. C G� !G'i pV vii.`,��
/T L....�J L.✓�V..�a...n '��Y`J / i Y � .��l^'��i ✓�✓ °{ -� `� � L°� .�..�w`�...�� f!�G7 lJ�� � "1 t G.� _�.
Please submit completed forms to the Building Inspections Division via mail, fax or email.