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670 Lone Oak Rd - Septic Maintenance Form 2012-06-22
City of 3830 Pilot Knob Rc Eagan MN 55122 Phone: (651) 675 -5 Fax: (651) 675.569 Email: commdevel Date Pumped: Site Address: Owner's Name: Condition of Baffles: Pumped Through: Comments: Owner's Address (if different Maintainer's Name: Private Residence: Please subm Eapll a 75 Pme ntRcityoteaga n, com # of Tanks Pumped: Total Gallons Pumped: ) DO 0 01'16 DcJC,, fc� .om site): t • f Y1 Y /'L'Qr (e\ c For Office Use ^ -� Date Received; / Staff: SEPTIC SYSTEM MAINTENANCE FORM SC C��N 1�10dC�C� ( `icw.11.,65 ervr.f $ L C- C License Number: g9 Commercial: Disposal Location: .erAp bCa Type of Tanks: rC Size of Tanks: 1 V© ) Effluent Sewage Discharge: Yes: No: X completed forms to the Building Ins pections Division via mail, fax or email. Q O f20V1 Ncsl ycGzt, NED