906 Lakewood Hills Rd - Septic Maintenance Form 2017-10-06Date Pumped: �j &1�� 0 / ] # of Tanks Pumped: Total Gallons Pumped
Site Address:
Owner's Name: k(�-/ �� aZSje5-.tJ
Owner's Address (if different from site):
Owner's Email: A`�AJ %,6- &7Z5 Gj �� (:e ✓ Owner's Phone #:
Maintainer's Name: 'I to NiiQ. �3 License Number:
e
Private Residence: _ Commercial
Condition of Baffles:
Pumped Through:
Comments:
Disposal Location:
Type of Tanks:
r?
Size of Tanks:
Effluent Sewage Discharge: Yes: No:
You may subscribe to receive an electronic notification from the City of proposed ordinances by signing up for an email update
on the City's website at www.cityofeagan.com/subscribe.
Please submit completed forms to the Building Inspections Division via mail, fax or email.
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For Office Use
Date Received: I
EAGAN I
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I
I I
I Staff: 1
3830 PILOT KNOB
ROAD I EAGAN, MN 55122-1810 1-------------------- 1
(651) 675-5675 1 TDD: (651) 454-8535 1 FAX: (651) 675-5694
buiIdinginspections
a(�.cityofeagan.corn
SEPTIC SYSTEM MAINTENANCE FORM
Date Pumped: �j &1�� 0 / ] # of Tanks Pumped: Total Gallons Pumped
Site Address:
Owner's Name: k(�-/ �� aZSje5-.tJ
Owner's Address (if different from site):
Owner's Email: A`�AJ %,6- &7Z5 Gj �� (:e ✓ Owner's Phone #:
Maintainer's Name: 'I to NiiQ. �3 License Number:
e
Private Residence: _ Commercial
Condition of Baffles:
Pumped Through:
Comments:
Disposal Location:
Type of Tanks:
r?
Size of Tanks:
Effluent Sewage Discharge: Yes: No:
You may subscribe to receive an electronic notification from the City of proposed ordinances by signing up for an email update
on the City's website at www.cityofeagan.com/subscribe.
Please submit completed forms to the Building Inspections Division via mail, fax or email.