755 Diffley Rd - Septic Maintenance Form 2016-11-22 ---------------------
For Office Use
I I
Date Received:
City of I Staff: I
1---------------------1
3830 Pilot Knob Road
Eagan MN 55122 22
Phone: (651) 675-5675
Fax: (651)675-5694 �S
Email: commdevelo ment(&cit ofea an.com
ID4, kq ) er v;r�s' �Sl� r`s �3719
f EPTIC SY TEM MAINTENANCE FORM ale (,q l�� f 4e�r S��'vi c�S o Dot r S' /,(
Date Pumped: 6 /-,-7�2- #of Tanks Pumped: Total Gallons Pumped: ` .5-oo
Site Address: t 7 e
Owner's Name: �" U /4 r G 14
Owner's Address(if different from site)::tf
Maintainer's Name: J k W k -S-L-r "-fes License Number:
Private Residence: V/ Commercial: Disposal Location:
Condition of Baffles: �a Q/1 pL Type of Tanks: C oh G rd e- Size of Tanks: j o o
Pumped Through: Effluent Sewage Discharge: Yes: No:
Comments:
Please submit completed forms to the Building Inspections Division via mail, fax or era' �1V7"it 2 40 L! �(, / C�
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Schlomha Services
Family Owned & Operated Since 1939
13450 122nd Street S
Hastings, MN 55433
651-459.3718 schfomkaservices.com
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