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526 Lone Oak Rd - Septic Maintenance Form 2021-12-13 --------------------- Fer ol6eelM EAGAN I � Dary Recebed: I i 1 Silt: I TI____________________� 3830 PILOT KNOB ROAD I EALAN.5'W S5I[2.713:0 (6511675-5675(FAX:(551)675-5694 Plan Submittal w(ansaL4yofee2dff.com SEPTIC SYSTEM MAINTENANCE FORM /l Date Pumped. 1.2VI J d 1 0 of Tanks Pumped. PPunnwed: m 5 o v Site Aoo+e zz. Sot Ci'd ez d) Owner s Name: Q Owner's Address If Offarent from sale): Owner s Emei Owrreis Plana e Melntaners Name: / r JQ.c.A.VtJ O�vA4.'�ChJ L�1/-tCp J lkanae Number. �� 5 Private Residence: ✓ cornmierelal: Disposal Locabon: Vj Condition of Battles: _ U h,�ir_v�.t�.V _ Type of Tana: Q'.,� Sae of Tanks: Pumped Thfouqh: Ef sued Sewstfe Dischame: Yet: _ No. _L Comments Name of Person ComWkrlslq Form: f, l ^'^e ^ n... ///, You may subscribe to receive an efeetronk notification from the City of proposed ordinances by signing up for en email update On the City's website at W1ye.WYQ1`AUdlLCQfn;505Ln1J1 Please submit completed forms to the Building Inspections Division via mail,fax or email.