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
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Owner's Address (if different from site):
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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: