3344 Sibley Memorial Hwy - Septic Maintenance Form 2016-06-22 ---------------------
For Office Use !
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� Date Received: i
City o1 f Eajan i Staff: r
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3830 Pilot Knob Road
Eagan Mil 55122
Phone: (651) 675-5675
Fax: (651)675-5694
Email: commdevelopmentOcitvofeagan.com
SEPTIC SYSTEM MAINTENANCE FORM
Date Pumped: _" 42 /1(o #of Tanks Pumped: _ Total Gallons Pumped: �Q
Site Address: 1 e W MeMr, af w ctij
Owners Name: NEN �
Owner's Address(if different from site):
Maintainer's Name: 77464o _ License Number: g
Private Residence: Co mercial: Disposal Location:
Condition of Baffles: Type of Tanks: C_ Size of Tanks: a/ Lie)
Pumped Through: Y22,aA`L Effluent Sewage Discharge: Yes: No:
Comments:
Please submit completed fors to the Building Inspections Division via mail,fax or email.