1674 Riverton Pt - Septic Maintenance Form 2012-06-01Jul 06 12 10:31a Greg Gudbjartsson
41 !! City of Eapil
3830 Pilot Knob Road
Eagan MN 55122
Phone: (651) 675 -5675
Fax: (651) 675 -5694
Email: commdevelopment ftcityofeagan.com
Date Pumped:
Site Address:
Owner's Name:
Owners Addres
Maintainer's Name:
Private Residence:
Condition of Baffles:
Pumped Through:
Comments:
SEPTIC SYSTEM MAINTENANCE FORM
( L. # of Tanks Pumped:
� _ 1
`�retr' - e\ /11 n , 411\
0
s (if different from site):
952- 469 -3963 p.2
Lit t= . �
af V License Number: � 5 ,
Disposal Location: R' I 1Z 1- F
Commercial:
o ic-
ikt49(Q_
Type of Tanks:
Effluent Sewage Discharge: Yes:
For Office Use
Date Received:
Staff: 2
Total Gallons Pumped: t Sj
Size of Tanks: ( .j 6
Please submit completed forms to the Building Inspections Division via mail, fax or email.
No: �Q