912 Lakewood Hills Rd - Septic Maintenance Form 2021-10-052021-10 - 28 17:22
LaRoche's Sewer 555 555 5555 » P 1/1
401'1 CityofEaQali
3830 Pilot Knob Road
Eagan MN 55122
Phone: (651) 675-5675
* Fax: (651) 675.5694
Email: commdevelopmentAcityofeagan.com
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For Offico Uso
Date Received:
Staff:
WP
r
SEPTIC SYSTEM MAINTENANCE FORM
Date Pumped: 4b6r i ,k>DA # of Tanks Pumped:
a
Total Gallons Pumped: atop
Site Address: • T 1 `�.,\--aMetbnoca O CCl C r\
Owner's Name:
Owner's Address (if different from site):
Maintainer's Name:
Private Residence:
Condition of Baffles:
Pumped Through:
Comments:
.
Commercial: Disposal Location:
Qnroitcr
QUitiew \LLic&v.,t)Qatcs
Type of Tanks: C. X
c_ ��l�S
�U License Number: 'O14.—
e UST IP Vwfm.idy\9"t'OtA.
Size of Tanks: k‘g.O .Q Q c0•
Effluent Sewage Discharge: Yes:
No:
X
Please submit completed forms to the Building Inspections Division via mail, fax or email.