904 Lakewood Hills Rd - Septic Maintenance Form 2016-06-20 -------------
For Office Use —I
JUL U 5 2016 Date Received:—
City of EaRao
I Staff: ----- -- i
3830 Pilot Knob Road I—`------------------
Eagan MN 55122 RECEIVED
Phone: (651) 675-5675
Fax: (651) 675-5694 MI
Email: commdevelopmentanityofeagan com
SEPTIC SYSTEM MAINTENANCE FORM
Date Pumped: �90 _){° #of Tanks Pumped: Total Gallons Pumped:
Site Address O Ll Ila EeWbori N(' Is
Owner's Name , yyxfT
Owner's Address(if different Srom site):
Maintainer s Name {��' t `S i License Number:
Private Residence: V/ Commercial: Disposal Location: Due, La ye
Condition of Baffles: ( I
n,,- Type of Tanks: b L Size of Tanks: j�d
Pumped Through: / V V-k 1 11 Effluent Sewage Discharge: Yes: No:
Comments:
Please submit completed forms to the Building Inspections Division via mail, fax or email.
---------------------
For Office Use
C),,tQ Received:
Uf bpfl I Staff
3830 Pilot.Knoh. Pcad L------------
att k
Fa)(: (65i)075-5-694
s!Z En. c 0,
13EPTIC SYSTEM MAINTENANCE FORM
6 of Tanks Pure pe-cl:
Total Gallons Pumped: (C✓Uj
Site Addr, as: IJ
Owner's Nacnw
0ner"s Address(11,different frr—unl site).
Mainisinar'a f4ame,
License klumt)er:
Privata Rtsidence: Is,/ Commercial: Disposal Location: v,-, L- 11 a
Jl�l I,.,-—1i,trl
Condition of B;;;le:;: 02.. ""1 —
—
Type of I anks:
Pumped Through: P Size of Tanks:
Effluent Sewage Discharge: Ycs: N10:
DAKOTA COJUN7-Y SEWAGE SYSTEM MAWTENANCE LOG
PU111POr Name /1/11(ias
Report--/—
No of!a'fifv.a Purnd- Tolal C-allons Pumped:
Owner-
Site Addr6w,.
Mumcipa4zy/'To�,,vnshjp 10 IL
0wrier Add.ess:
J&Pnva et' Pesidence ❑ 13ental OCommerciijl (Owner cfs_:�scdj)p_r_f jy,,
Qt iji
S i nl�.(s) []`f'-_:�s C] No)
eptage Disposal Location-
Typ,? of Tank(s) 'It Cundftion of les-
2 3
ePfi --
Oc tank holdinq Casspo 1a`n1-, sznd Ttr,�p, ItYE(Er 4tmp, etc.)
Size of Tan.4;(s) 1_/ "Mp
0�p
2 3
PUmPeG through,- E_"�;an-hole lnspacajon RN Effluent Surfaci,; Oischsraa• n YPS E-��Vpqa
Comments:--
Mike's Septic Service Sales Receipt
1.6961 Mushtown Road
Prior Lake, A/Y, 55372 Date Sala No.
952440-1800
L6/20/2016 12627
Sold To
Gmach,Matt
904 Lakewood Hills Road
Eagan,MN 55123-1912
Check No. Payment Method Project
Discover
Description Qty Rate Amount
Pumping Septic System I Tank Manhole 1 200.00 200,00
Metropolitan Waste Dumping Charge 1 75.00 75.00
Permit sent to Dakota County and City of Eagan
PAID IN FULL
Thank you for your busiucssl Cody McKinley T 0 $275.00