3083 Sibley Memorial Hwy - Septic Maintenance Form 2012-09-05City ofEa all
3830 Pilot Knob R ad
Eagan MN 55122
Phone: (651) 675.5 75 . .
Fax: (651) 675.569
Email: commdevelopment (a7cityofeacgan.com
For Office Use
Date Received: O 7 51
Staff:
SEPTIC SYSTEM MAINTENANCE FORM
Date Pumped: ` ."" .--I IL # of Tanks Pumped: 2 Total Gallons Pumped:
Site Address;
3 0 3 ,L,. 11 / ine4OLa U \; ec.a Or
Owner's Name: UJ t3.., h2.- }- (DCAA tA\.eC / 4 j
'Tom site):
Owner's Address (if different
Maintainer's Name:
Private Residence:
Condition of Baffles:
Pumped"Througfi'"-
Comments:
iZc
SW-0 vvtilCOL •
Commercial:
ch C/\
Disposal Location:
License Number:
e 2 St; YotAwt lU w T
Type of Tanks: 5e„(I.7'� Z,, Size of Tanks: %,t1G7
Effluent Sewage Discharge: Yes: No: le-
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Please subm
iI completed forms to the Building Inspections Division via mail, fax or email,
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