915 Lakewood Hills Rd - Septic Maintenance Form 2017-07-12 2011-04-21 02:23 » 6516755694 P 111
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� Date Received; LO 0- I
City of Eaelft I---------------------1 1
3630 Pilot Knob Road
Eagan MN 55122
Phone; (651)675.5675
Fax: (651)675.5694
Email:Eommdev loamentOcitvofeaaon.com
SEPTIC SYSTEM MAINTENANCE FORM
Date Pumped; -' 2 I #of Tanks Pumped: Total Gallons Pumped: `/ ocu
Site Address: C,I �7 (i F})Z� 1JC6C :
Owner's Name:
Owner's Address(f different from site):
Maintainer's Name: k— C�,Lus- Sege C. eu,, p l�� License Number; L `7
Private(Residence; __ZCommerclal: Disposal Location: r1V1 P 4
Condition of Baffles: 8LC Type of Tanks: L1(0f< (--- Size of Tanks; Day
Pumped Through: T/40) 1 Ptr Effluent Sewage Discharge: Yes: No:
Comments; �?'T W 14gT W 4 OL)1 4105 6,
Please submit completed forms to the Building Inspections Division via mall,fax or email,
SEPTIC PU.
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CUSTOMERS ORDER NO PHONE DATE
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SOLD BY CASH CAD. CHARGE ON ACCT MDSE.REr D. PAID OUT
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THANK YOU
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