1436 Highview Ave - Septic Maintenance Form 2012-06-06Jul 06 12 10:31a Greg Gudbjartsson
City of EaQall
3830 Pilot Knob Road
Eagan MN 55122
Phone: (651) 675 -5675
Fax: (651) 675 -5694
Email: commdevelopment (c� citvofeagan.com
Date Pumped:
Site Address:
Owner's Name:
Condition of Baffles:
Pumped Through:
Comments:
ILI:30 PO
R741Rt-C° - t
Owner's Address (If different from site):
� C;
Maintainer's Name: �� eiCL'-.C'1
Private Residence: Commercial:
SEPTIC SYSTEM MAINTENANCE FORM
# of Tanks Pumped: — Z__ Total Gallons Pumped:
NL
Disposal Location:
Type of Tanks:
952- 469 -3963
e ;UC=
For Office Use 1n
Date Received: 11 a 1 1 `
Staff:
e' ,
License Number: �` �� f '
ICJ c-P
Size of Tanks:
p.3
Effluent Sewage Discharge: Yes: No:
Please submit completed forms to the Building Inspections Division via mail, fax or email.