No preview available
 /
     
3432 Hwy 55 - Septic Maintenance Form 2017-02-15 2010-11-05 14:04 }> 6516755694 P 2/2 For ca --------------- I I Date Recelved; 2 I 2d t f City of . 3430 Pilot Knob Road L--MN 55122 — Phone:(651)675.5675 Fax:(651)675-5694 Email: o m ev o e t it fe a ,com SEPTIC SYSTEM MAINTENANCE FORM Date Pumped: _ `2-1 y- / #of Tanks Pumped; 2. Total Gallons Pumped; 2o ,3 Z Site Address: 31— .. Owner's Name: Owner's Address(If different from site): Maintainer's Name: e �,., ,�- � r C • License Number: L Private Residence: Commercial: G _ Disposal Location: Condition of Baffles: Type of Tanks: of 69L3 J, , !a . c /��1t, T4 Pumped Through: /�` � Size of Tanks: Effluent Sewage Discharge: yes, No: (� Comments: D�;�� c- Please submit completed forms to the Building Inspections Division vie mall,fax or small.