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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.