906 Lakewood Hills Rd - Septic Maintenance Form 2022-12-08Ah,6
4'r CA, of Up
3830 Pilot Knob Road
Eagan MN 55122
Phone: (651) 675-5675
Fax -.(651)675-5694
Email: commdevelo ment cit ofea an.c®m
1 For office Use I
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I Date Received: '
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1 Staff: _ ---
SEPTIC
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SEPTIC SYSTEM MAINTENANCE FORM
Total Gallons Pumped: A1C L }
# of Tanks Pumped: -�---- ---
Date Pumped:
Site Address:
/11
owner's Name:
Owner's Address (if different from site): _-- -- --- �f-�� License Number:
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Maintainer's Name: r
Commercial: Disposal Location: v
Private Residence: _____ c YYPe of Tanks: Size of Tanks:
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Condition of Baffles: Yes: No: v--'--
EffiuentSewage Discharge: — ---
Pumped Through: / l�
Comments:
s� Inspections Division via mail, fax or email.
Please submit completed forms to the Building