3815 Nicols Rd - Septic Maintenance Form 2017-08-16 For Office Use
- i E
City � Date Received: E
afl I Staff: I
3830 Pilot Knob Road
Eagan MN 55122
Phone : (651 ) 675*.5675
Fax: (651 ) 675%.5694
Email : cflmmdevelo meat cit ofea an,corn
SEPTIC SYSTEM MAINTENANCE FORM
Date Pumped: � � � r b # of Tanks Pumped : I;L Total Gallons Pumped: = 1
Site Address-, g-3 /
Owner's Name: •
Of
Owner's Address (if different from site): x
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Maintainer's Name: "CAI. 5 SC-XA.& V- ��ta�� Y1 � G &Vl �1 (LS License Number: D
Private Residence.: Commercial: isposal� Location :
Condition of Baffles : k-a C,-. M Type of Tanks. S'10— �1 C x L Size of Tanks : "ewjaC.h% X
Pumped Through : LA \ JR4WS d�e.Y ',-QC,� 1 Effluent Sewage Discharge: Yes : No:
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Please submit completed forms to the Building Inspections Division via mail, fax or email.