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915 Lakewood Hills Rd - Septic Maintenance Form 2017-07-12 2011-04-21 02:23 » 6516755694 P 111 ForOr--- -------------I I /( I � 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. Vallay V*1-7w 9. 0. 4. pq 8 CUSTOMERS ORDER NO PHONE DATE NAME L ADDRESS "N 1k SOLD BY CASH CAD. CHARGE ON ACCT MDSE.REr D. PAID OUT eM s Or Over ExWses 3rwiu,&E.Remwin-SW4 A4Xle" To !nclude Uvn TAX RECEIVED BY TOTA I CI j fj )-i All claims and returned goods MUST be accompanied by this bill. THANK YOU P Y