550 Diffley Rd - Septic Maintenance Form 2012-04-02c-.1)
City of Eapt SN 1 7 25‘
3830 Pilot Knob Road
Eagan MN 55122
Phone: (651) 675-5675
Fax: (651) 675-5694
Email: commdevelopmentRcityofeagan.com
Date Pumped:
Site Address:
Owner's Name:
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Owner's Address (if different from site): it r .1
Maintainer's Name:
Private Residence:
Condition of Baffles:
Pumped Through:
Comments:
SEPTIC SYSTEM MAINTENANCE FORM
Pc O # of Tanks Pumped: (7Y\
O NAN V\P-- ce5
Commercial: Disposal Location:
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Type of Tanks:
For Office Use
Date Received:
Staff:
Effluent Sewage Discharge: Yes:
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Total Gallons Pumped: /000
6 57a3
Q 4 1/1 "
1411V 5.57,Q 3/
License Number:
\TA e-f 0 51 pcza I
P.17/7a..--Size of Tanks:
Please submit completed forms to the Building Inspections Division via mail, fax or email.
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No: