520 Lone Oak Rd - Septic Maintenance Form 2016-06-02 RECEIVED
JU1,11 032016
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For Office Use
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I Dale Received: 3 I
City of Eapn Staff:
1_____________________
3630 Pilot Knob Road
Eagan MN 55122
Phone: (651)675-5675
Fax: (651)675-5694
Email: commdevelonment(a-citvofeaaan.com
SEPTIC SYSTEM MAINTENANCE FORM
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Date Pumped: C3 ��� #of Tanks Pumped: Total Gallons Pumped: / V 02
Site Address: Tin L-On e
Owner's Name:
Owner's Address(if different from site):
Maintainer's Name: �(ryi5 ��� ��} `�� ��+;( License Number:
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Private Residence: X Commercial: Disposal Location:
Condition of Baffles: Type of Tanks: C to:-1 (r Size of Tanks:
Pumped Through: �Jfb,Al Effluent Sewage Discharge: Yes: No: --�'
Comments:
Please submit completed forms to the Building Inspections Division via mail,fax or email.
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