1260 Deerwood Dr - Septic Maintenance Form 2016-10-13 2010-07-04 02:54 » 6516755694 P 3f3
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For Office Use I
I 11
411� Date Received;t b - I
City of �
I Staff:I------ --------------1
3930 Pilot Knob Road
Eagan MN 55122
Phone: (651) 675-5675
Fox:(651) 875-5094
Email: commdeveloomgntftltyofea%ian corn
SEPTIC SYSTEM MAINTENANCE FORM
Date Pumped: ±l� 3 #of Tanks Pumped: "total Gallons Pumped:
Site Address: `/` Vs6u
owner's Name:
3"er's Address(if different from site):
.Maintainer's Name: / 1„oa � 5�P7iC,_. �iJl�'Ipl�5 License Number; L
Private Residence; t./ Commerolak Disposal Location: �6. t� J�j(f/ bw-
Condition of Baffles: 6WQ Type of Tanks: P s�Ti C- Size of Tanks: /ooy
Pumped Through: /�'�A��,�f�� Effluent Sewage Discharge: Yes; No:
Comments:
Please submit completed forms to the Building Inspections Division vie mail,tax or small.