904 Lakewood Hills Rd - Septic Maintenance Form 2014-06-18 ---------------------
For Office Use
I I
Date Received:
City of Ea aIl I
I Staff: I
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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: a `y #of Tanks Pumped: \ Total Gallons Pumped:
Site Address: 0.J L4�Ltk4 �S
Owner's Name: �- �
Owner's Address(if different frolm' site):
Maintainer's Name: License Number.
Private Residence: Commercial: Disposal Location: 4`lna �
Condition of Baffles: Type of Tanks: Size of Tanks: 400 qw�.
Pumped Through: 1�.,,, �- Effluent Sewage Discharge: Yes: No: _ C�
Comments:
Please submit completed forms to the Building Inspections Division via mail,fax or email.
DAKOTA C0UHTY SEWAGE SYSTEM HAHTCK° MC E LOCH
pumpar Name Rapnr��—/&
Date Pumped:-�J-/�/ )(1 N . of Wanks Pumped: Total Gallons Pumped: 1 C-60 / I
Owner r��' i��Q i MCA Site Address:
i4lunicipalitty/Township: Owner Address:
Private Residence ❑ Rental ❑Commercial(Owner described type of tank(s) C1 Yes C1 No)
Septage Disposal Location: uk,Ir�-' Condition of Baffles:
Type of Tank(s) 1 i G 2 3
(:yep is tank olding t nk, cesspool, pump tank,sand trap,flammable water trap, etc.)
Size of Tank(s) 2 3
Pumped through: bean-hole fnspection Pipe Effluent Suriaw Discharge: ❑ Yes Ho
Comments:
ibs trdial �Sh mftcr fl R sst2as cal A st' T 1 i 3 16 Arm
Mikes Septic Service
16961 Muslitown Rd
Prior Lake- I-IN 55372
IERMIIIAL I.D.: 067600
HERCHAiII 0 1 21370043336301
1)I SCOUER
i40041005815#
SALE
BATCH: 0003336 I NU: 000001
DATE: JUII 19, 14 TIME: 07:48
Rill: 03360001 AUT H-01951R
CUU2: M
TOTAL $275.00
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I AGREE TO PAV ABOUE TOTAL HUM
ACCOR0I116 10 CARD ISSUER AGRER1111
(MERCHAIII A6REEIVII IF CREDIT VOUCHER)
MERCHAHi COPV