3434 Hwy 55 - Septic Maintenance Form 2017-02-15 2010-11-05 14:03 }> 6516755694 P 1/2
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For office use
60 4 Date Received: 2 IS 2oj
City of Ea aIl
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3830 Pilot Knob Road
Eagan MN 55122
Phone:(651)675-5675
Fox: (651)675-5694
Email: commdevelopment0cityofeaaan com
SEPTIC SYSTEM MAINTENANCE FORM
Date Pumped; —2--Ly L� #of Tanks Pumped: Total Gallons Pumped: uU
Site Address: r; 44 3-( ! • F ',-t7
Owner's Name:
Owner's Address(If different from site):
Maintainer's Name: A�I—t-sr sr J C"p�� C. PV mPi� License Number:
Private Residence: JL-," Commercial: Disposal Location: 9W 2 Q L
Condition of Baffles: ,�u a:'� T ype o ('ZdCT
f Tanks: �'�'� L Size of Tanks: 0 O �- L
Pumped Through: M R x 1.1yl Effluent Sewage Discharge, Yes: No:
Comments; Q 2 Cl v.�'s- � �`1 [ �/, i _-f
Please submit completed forms to the Building Inspections Division vie mall,fax or email.