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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 %L C?7 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: c C��Cl eacv kx kinC S�k �COZO .S Please submit completed forms to the Building Inspections Division via mail, fax or email.