3336 Sibley Memorial Hwy - Septic Maintenance Form 2012-06-07Jul 06 12 10:32a
City of
Date Pumped:
Site Address:
Owner's Name:
Owner's Address (if different from site):
Maintainer's Name:
Private Residence: \C.! Commercial:
Condition of Baffles:
Pumped Through:
Comments:
Greg Gudbjartsson 952- 469 -3963
3830 Pilot Knob Road
Eagan MN 55122
Phone: (651) 675 -5675
Fax: (651) 675 -5694
Email: commdevelopment Acityofeagan.com
SEPTIC SYSTEM MAINTENANCE FORM
- 17- # of Tanks Pumped:
3 75
/hit liktxeL
Disposal Location t...0 A
For Office Use
Date Received:1
Staff:
P.5
1,2
Total Gallons Pumped: 1 Z3
License Number:
i,u w 11
Type of Tanks: Size of Tanks: / Z- :> C'
Effluent Sewage Discharge: Yes: No:
Please submit completed forms to the Building Inspections Division via mail, fax or email.