578 Michigan Ct - Septic Maintenance Form 2020-09-172020-09-22 17:05
LaRoche's Sewer 555 555 5555 » P 1/1
411,11 CityofEa�all
3830 Pilot Knob Road
Eagan MN 55122
Phone: (651) 675-5675
Fax: (651) 675-5694
Email: commdevelopmentpcitvofeagan.com
For Offlco Uso Oj
Date Received:
Staff:
L
SEPTIC SYSTEM MAINTENANCE FORM
Date Pumped: - 1 — 19 — aQ # of Tanks Pumped: a- Total Gallons Pumped: I) 10
Site Address: 5 1 M I Gtt 1 Q G1,ir1 wl11.- t
Owner's Name: BolD 1 a_h_o Jn e �(
Owner's Address (if different from site):
Maintainer's Name: LD QCkR S S-e—tA X :tiro T.\ E Secii License Number: �O
Private Residence: Commercial: Disposal Location: —C.1/4 G cl a'
Secrki L /000
Condition of Baffles: r\c4 r1 Type of Tanks: Q u J \0. .t. + Size of Tanks:
Pumped Through: U1 eC-kihn p l S Effluent Sewage Discharge: Yes:
Comments:
No:
Please submit completed forms to the Building Inspections Division via mail, fax or email.