1674 Riverton Pt - Septic Maintenance Form 2017-05-26 --------.—__—�
I For Office Use— i
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I Date Received: JAA 1:1
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City of Eajan j Staff:
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3830 Pilot Knob Road
Eagan MN 55122
Phone: (651) 675-5675
Fax: (651) 675-5694
Email: com md eve lopmentC&_cityofeagan.com
SEPTIC SYSTEM MAINTENANCE FORM
Date Pumped: -ate — -p #of Tanks Pumped: I JC7C Total Gallons Pumped: Sao
Site Address: ��1 'l t`�t V'ey-+., T,: %Tyk
Owner's Name: GG y r
Owner's Address (if different from site):
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Maintainer's Name: GA%ZS License Number:
Private Residence: X Commercial: Disposal Location:
Condition of Baffles: 1C�S41 G Cc]ot Type of Tanks: Size of Tanks: I SoC�
Pumped Through: k t ap 3 Effluent Sewage Discharge: Yes: No:
Comments:
j`M1�' `. Please submit completed forms to the Building Inspections Division via mail,fax or email.