4670 Nicols Rd - Septic Maintenance Form 2012-06-20Jul 06 12 10:32a Greg Gudbjartsson
city of Evan
3830 Pilot Knob Road
Eagan MN 55122
Phone: (651) 675 -5675
Fax: (651) 675 -5694
Email: commdevelopment Acityofeacian.com
Site Address:
Owner's Name:
952- 469 -3963
SEPTIC SYSTEM MAINTENANCE FORM
For Office Use �]
Date Received: F /
Staff.
P.7
Date Pumped: tZ--
# of Tanks Pumped: / Total Gallons Pumped: / Z ,SC
2167C) tO
(�: ��`` —'
N.
P
r \ 5 (co t - ��'l L cc] (,'
Owner's Address (if different from site):
Maintainer's Name: � \&14/ License Number: Z- 7
�- {�._
Private Residence: Commercial: Disposal Location: f� `� �� 1 E
Condition of Baffles:
0 /C_ • Type of Tanks: Size of Tanks: l Z- -.<
�'j (J " Effluent Sewage Discharge: Yes: No: t�
Pumped Through: file Ef
�
Comments:
Please submit completed forms to the Building Inspections Division via mail, fax or email.