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3434 Hwy 55 - Septic Maintenance Form 2017-02-15 2010-11-05 14:03 }> 6516755694 P 1/2 --------------------- For office use 60 4 Date Received: 2 IS 2oj City of Ea aIl E ------------------- 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.