870 Lakewood Hills Rd - Septic Maintenance Form 2016-06-23 2010-03-27 00:24 » 6516755694 P 3/3
For Office Use – I
I I
I
Cit OII p Eap Da►e Received:I
I Staff: l
I
3830 Pllot Knob Road ----------------- --!
Eagan MN 55122
Phone: (651)675-5675
Fax:(651)675.5694
Email: Comm 'eveloampnt(�cltyofea4an com
SEPTIC SYSTEM MAINTENANCE FORM
Date Pumped; �' 23 /C— #of Tanks Pumped: Total Gallons Pumped: QVCj
Site Address; '?Q (�� f� Wo6 Y3 r)o L
T
Owner's Name: r1l g' IJ� Ar
Owner's Address(if different from site):
Maintainer's Name: _ ��� S�7i
f License Number:
Private Residence: Commercial
Disposal Location: ,L
Condition of Baffles: Qp—fj �,`,�
Type of Tanks: r(_ r' rSize of Tanks: Avib
Pumped Through; /Vl fya�fQ�br
' Effluent Sewage Discharge; Yes: No:
Comments;
Please submit completed forms to the Building Inspections Division via mail,fax or email.