894 Lakewood Hills Rd - Septic Maintenance Form 2017-07-26 RE CE IV E-0 ---------------------
For Office Use
2 0 2017 1 I
a _ i Date Received:
r
City of Enn I Staff:
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3830 Pilot Knob Road
Eagan MN 55122
Phone: (651) 675-5675
Fax: (651) 675-5694
Email: commdevelopment C&cityofeagan.com
SEPTIC SYSTEM MAINTENANCE FORM
Date Pumped: , #of Tanks Pumped: Total Gallons Pumped: 4 C3C�o
Site Address: a
Owner's Name:
Owner's Address(if different from site): �7
Maintainer's Name: /!, KSLicense Number: rid
.F n, 5s-o�
Private Residence: Commercial: Disposal Location: Ll1
Condition of Baffles: k,�— Type of Tanks: c� Size of Tanks: ::� p-v
Pumped Through: �. k ,p� Effluent Sewage Discharge: Yes: No:
Comments:
Please submit completed forms to the Building Inspections Division via mail, fax or email.