1215 Diffley Rd - Caponi Art Park - Septic Maintenance Form 2016-10-05 ---------------------
For Office Use
I I
I Date Received:
City of Eap I
I Staff: I
3830 Pilot Knob Road
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Eagan IVIN 55122
Phone: (651) 675-5675
Fax: (651) 675-5694
Email: commdevelopment(cDcitvofeaoan.com
SEPTIC SYSTEM MAINTENANCE FORM
Date Pumped: 'Q)— 5- Z � #of Tanks Pumped: 1i Total Gallons Pumped:
Site Address:
Owner's Name: (� �y
Owner's Address(if different from site):
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Maintainer's Name: r�C}��,C�C }25 License Number:
Private Residence: Commercial: Disposal Location: mp\rte W7 S
Condition of Baffles: Type of Tanks: Size of Tanks:
Pumped Through: Effluent Sewage Discharge: Yes: No: ,n
Comments:
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Please submit completed forms to the Building Inspections Division via mail,fax or email.
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