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578 Michigan Ct - Septic Maintenance Form 2021-09-232021-09-30 11:32 LaRoche's Sewer 555 555 5555 » P 1/1 41,11 CityofEaQali 3830 Pilot Knob Road Eagan MN 55122 Phone: (651) 675-5675 * Fax: (651) 675-5694 Email: commdevelopmentacitvofeagan.com For Office Uso Date Received: ! 3 o / 2024 Staff: SEPTIC SYSTEM MAINTENANCE FORM Date Pumped: "►- Z" eD # of Tanks Pumped: (D" Total Gallons Pumped: Lb l Q Site Address: S . % M l Gk1..‘Qv-\, tout `(A .• Owner's Name: ; . te,C:tO 1&r c ,i ,,, N\ Owner's Address (if different from site): 1 Maintainer's Name: �5 License Number. Sca" Private Residence: Commercial: Disposal Location: ‘-.a12411'Re��- sz,p• G t 'COO Condition of Raffles: UnVA"\Own, Type of Tanks: rv, vo,��4. Size of Tanks: — 8c> Pumped Through: Comments: Effluent Sewage Discharge: Yes: No: Please submit completed forms to the Building Inspections Division via mail, fax or email: