3296 Sibley Memorial Hwy - Septic Maintenance Form 2012-06-08Jul 06 12 10:32a Greg Gudbjartsson
d '
City of kali
3830 Pilot Knob Road
Eagan MN 55122
Phone: (651) 675 -5675
Fax: (651) 675 -5694
Email: commdevelopment Pcityofeagan.com
Date Pumped:
Site Address:
Owner's Name:
Comments:
Owner's Address (if different from site): ?IS , 3CG , L ( ,
l
Maintainer's Name:
License Number:
t ,,
Disposal Location: V+`� b %7 uc' C�
Private Residence: Commercial: P
Condition of Baffles:
Type of Tanks: Jt i'a Size of Tanks:
/'
Pumped Through: /J'((t (.L4' = (044 Effluent Sewage Discharge: Yes: No:
952- 469 -3963
For Office Use
Date Received:
Staff:j
SEPTIC SYSTEM MAINTENANCE FORM
p.4
it of Tanks Pumped: Z Total Gallons Pumped:
Please submit completed forms to the Building Inspections Division via mail, fax or email.