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
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II Staff
SEPTIC SYSTEM MAINTENANCE FORM
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# orranks pumped L
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Total Gallons Pumped:
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Maintainer's Name
Private Reside n"u. * Commercial
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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.
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