785 Diffley Rd - Septic Maintenance Form 2016-05-04 i
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For Office Use
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I Date Received:
City of Eap
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I Staff: I
3830 Pilot Knob Road
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Eagan MN 55122
Phone: (651)675-5675
Fax: (651) 675-5694
Email: commdevelopmenta(�citvofeaoan.com
SEPTIC SYSTEM MAINTENANCE FORM
Date Pumped:/ #of Tanks Pumped: Total Gallons Pumped: ! C?DU
Site Address: � i ""� -Z1
Owner's Name: C ".11�1,1�,
Owner's Address (if different from site): )"+
Maintainer's Name: License Number:
Private Residence: �f Commercial: Disposal Location: ',
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Condition of Baffles: Type of Tanks: Size of Tanks:
Pumped Through: Effluent Sewage Discharge: Yes: No:
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Comments: Ftt ntc �� /�' (�4tc- I I �acL &}= ) I-/CUC Z / Ibl(> !er16,)
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Please submit completed forms to the Building Inspections Division via mail,fax or email.