3350 Hwy 55 - Septic Maintenance Form 2017-09-20Ci of Ean
3830 Pilot Knob Road
Eagan MN 55122
Phone: (651) 675-5675
Fax: (651) 675-5694
Email: commdevelopment(&cityofeagan.com
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For Office Use
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Date Received: 20
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1 Staff: I
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SEPTIC SYSTEM MAINTENANCE FORM
Date Pumped: 7 V # of Tanks Pumped: Total Gallons Pumped: 6
Site Address: f4 to .a/ 55 , C /�C.� f� i�; ;21
7 r
Owner's Name: r,<_ C) y-nCt
Owner's Address (if different from site):
Maintainer's Name: \&-GL"_� VSO,x ej License Number:
-�
Private Residence: Commercial: Disposal Location:
Condition of Baffles: r /rj O-L�-d Type of Tanks: - Size of Tanks:
Pumped Through: Effluent Sewage Discharge: Yes: No: f/
Comments:
Please submit completed forms to the Building Inspections Division via mail, fax or email.