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640 Lone Oak Rd - Septic Maintenance Form 2020-03-11@f,ityorrasan 3830 pitot Knob Road Eagan MN S5122 Phone; (651) 67S-S67s Fax: (651) 675-5694 Email: Date Pumped: Site Address: Owner's Name Owner's Address (if different from I For Office Use II Date Received: I j II Staff SEPTIC SYSTEM MAINTENANCE FORM 'i/ qf ' '' # orranks pumped L r-i Total Gallons Pumped: t\7 Maintainer's Name Private Reside n"u. * Commercial .*O,,,on or e"rnu.[[j Pumped Through Comments: Disposal Location: pe of I anks Effluent Sewage Discharge: yes <---trln \- License Number: ,7q Qq sizeorranks \|"00 lQIA Please submit completed forms to the Building lnspections Division via mail, fax or email. /.1