896 Lakewood Hills Rd - Septic Maintenance Form 2016-09-01 --------- — — -- -- —
For Office Use — -- — — —
Date Received (
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I Staff:
City of um 1---------------------1
3830 Pilot Knob Road
Eagan I&K, 55122
Phone: (651) 675-5675
Fax: (651)675-5694
Email: corr.mdevelopmentO an.com
,_cityofeaqan.co_
SEPTIC SYSTEM MAINTENANCE FORM
Date Pumped:: #of Tanks Pumped: Total Gallons Pumped:
Site Addrew
-TsOwner's Name
Owner's Address of different from site)!
Maintainer's Name: %S L License Number:
Private Residence. X% commercial: Disposal Location.
Condibon of Baffles: c\ Type of Tanks. -;C c-- Size of Tanks:
Pumped Through; Effluent Sewage Discharge. Yes, No: it
Comments, IL� .�l
Please sublinfli completed forms to the Building Inspections Division via mail,fax cr email.