4395 South Robert Tr - Septic Maintenance Form 2015-01-15 RECEIVED
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,. AAR 7 9 Y016 For Office Use 5
Date Received: 130 I
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City of Ea are I I
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3830 Pilot Knob Road
Eagan IIIIN 55122
Phone: (651) 675-5675
Fax: (651) 675-5694
Email: commdevelo ment cit ofea an.com
SEPTIC SYSTEM MAINTENANCE FORM
Date Pumped: 1-2-7 /J #ofTanks Pumped: Total Gallons Pumped: 00
Site Address: °�r q5y J
Owner's Name: V A44 In
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Owner's Address(if different from site): 72o 1—Ak � ./ /#f A
Maintainer's Name: License Number:
�U$l 6&677
Private Residence: Commercial: Disposal Location:
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Condition of Baffles: G a o L Type of Tanks:4�� Size of Tanks: 50 b
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Pumped Through: _ 4(� O Effluent Sewage Discharge: Yes: No:
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Comments:
Please submit completed forms to the Building Inspections Division via mail,fax or email.
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