865 Lakewood Hills Rd - Septic Maintenance Form 2016-09-14 ---------------------
For Office Use
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Date Received: `
City of Ea o�Il I Staff:
6
3830 Pilot Knob Road
Eagan MN 55122
Phone: (651) 675-5675
Fax: (651) 675-5694
Email: commdevelopment(a-cityofeagan.com
SEPTIC SYSTEM MAINTENANCE FORM
Date Pumped: #of Tanks Pumped: Total Gallons Pumped:
Site Address:
Owner's Name:
Owner's Address(if different from site):
Maintainer's Name: ? /�✓c117/1/y�/� � License Number:
Private Residence: V Commercial: Disposal Location:
Condition of Baffles: C�< Type of Tanks: Size of Tanks:
Pumped Through: . �tyr Effluent Sewage Discharge: Yes: No:
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Comments:
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R Please submit completed forms to the Building Inspections Division via mail, fax or email61 ,;?0/W/,
ever—o 5325 MANNING AVE,SO.,AFTON,MN 55001
Family Owned Business Since 1976
LANA MEYER
(651)459-0162
r Liquid Waste Pumped•Portable Toilet and Sink Rental
www.MeyerSewer.com
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CHECK CASH CHARGE CREDIT CARD CHARGES DATE
PLEASE CALL
NAME
ADDRESS
N
AA
ADDRESS C
E
D E
CHECK
R SS
41 ,
PUMPED UMPED AND BACKFLUSHE6"
p T
0
T
Cesspool S
ei�iFpvu'
Holding Tank
Lift Station
Distribution or Junction Box
Extra Backflushing
— feet of hose(Extra charge for over 100 feet of hose)
Washington County Fee
PUMPED:
Sandtrap
Sump
Other:
Weekend or Evening Charge
RECEIVED EY
X TOTAL Z7
TOTAL GALLONS,
Pumped through manhole or inspectionrpe
Septic tank: Precast-Block-Plastic-Unknown-,
Overflow tank: Precast-Block-Plastic 1� rown"
Condition of baffle: Good, Repair Needed,or Unknown
Drainfield: Mound,Trench,or U96IR-Fi6Wn, --- ---
Effluent surface discharge: Yes o(N 6
Lift Station: Yesbr._o
Comments: A"
Licensed-Bonded•Insured
Li
MinnesotaTlu nSt Pollution
Control Agency`
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