4875 Pilot Knob Rd - Septic Maintenance Form 2020-08-272014-05-29 02:21 >> P 1/1
40' ty of E
3830 Pilot Knob Road
Eagan MN 55122
Phone; (661) 675-5675
Fax: (651) 6755694
Email: com evel men of0 n.com
� --------------------
For Office Use
I
I I
Date Received: I
I
I
I Staff
---_____
SEPTIC SYSTEM MAINTENANCE FORM
-)ate Pumped: �� # of Tanks Pumped.Total Gallons Pump;
%.
Site Address: 7 t r1W A71J
Owner's Name. ff
,)Wner'S Address (if df;ferent from site):
Maintainer's Name: �„� - ./G U/►' /� t.icense Number: L
Private Residence: Commercial: Disposal Location: nn `
,J
Condition of Baffles: Cu -)b Type of Tanks: C.
�Y- ^„ Size of Tanks;
Pumped Through: lG+-� I rc: Effluent Sewage Discharge: Yes; No:
Comments:
Please submit completed forms to the Building Inspections Division via mail, fax or email.