535 Red Pine Lane - Septic Maintenance Form 2016-05-18 ---------------------
For Office Use
5 25
City
RECEIVED i Date Received: 20 1�
I
ofEa an MAY 2j 2016 I Staff:
I 1
---------------------
3830 Pilot Knob Road
Eagan M N 55122
Phone: (651) 675-5675
Fax: (651) 675-5694
Email: commdevelopmentC@_cityofeagan.com
SEPTIC SYSTEM MAINTENANCE FORM
Date Pumped: #of Tanks Pumped: Total Gallons Pumped: oo
Site Address: 5 124EP l
Owner's Name: e-zc-94el /—0 4774Z-ONE-
Owner's Address(if different from site):
' l ' ^ License Number:
Maintainer s Name: �Z�1O r' G�, �< � `� ,�
Private Residence: Commercial: Disposal Location: t-),V\P
r CD
Condition of Baffles: Type of Tanks: �� Size of Tanks:
Pumped Through: G-�`��0�e Effluent Sewage Discharge: Yes: No:
Comments:
Please submit completed forms to the Building Inspections Division via mail,fax or email.