945 Butwin Rd - Septic Maintenance Form 2023-05-24 RECEIVE
JUN 0 5 2023
BY,
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For Office Use --- - -
EAGAN I Date Received:
3830 PILOT KNOB ROAD I EAGAN, MN 55122-1810 1 staff:
(651 675-56751 TDD: (651)454-85351 FAX: (651)675-5694
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SEPTIC SYSTEM MAINTENANCE FORM
Date Pumped: s Z4-7-.3
#of Tanks Pumped. 5
Total Gallons Pumped,
0
Site Address: C1 Ll �S -D V-V\A� ""-) IC,
Owner's Name:
J,,
Owner's Address if different from site):
Owner's Email:
Owner's Phone#:
Maintainer's Name:
,j
2
License Number:
Private Residence: Commercial: Disposal Location: \Q
Condition of Baffles: TYPe of Tanks; Size ofTanks: -S-fe— 7WO&At
Pumped Through: # o
Effluent Sewage Discharge; Yes: No: X
Comments:
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Please submit Completed forms to the Building inspections Division Via mail, fax or email.