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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 L_ 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.