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.