830 ONeill Dr - Septic maintenance 9/11/240
1 0
PO BOX 40
eyed
AFTON, MN 55001
Sealer 6
Family owned Business Since 1.976
SerV ce
(651) 459-0162
www.Meyersewer.com
CASH CHAR
CHECK
CREDIT CARD CHARGES DATE ^
PLEASE CALL r,�(
!p� ``
'NAME t ^ n, � G 11I
PUMPED AND BACKFLUSHED:
Pump (Lift) Tank l
Cesspool
Holding Tank
Sump i
Cleaned Filter
Used Crust Buster to break up thick crust
Extra Backflushing
feet of hose (Extra charge for over 120 feet of hose)
County Fee or City Fee
Disposal Fee
OTHER REPAIRS:
lily0 IcDv
Weekend or Evening Charge 7pollution
cTOTATOTAL GALLONS:.,�p
COMMENTS: �V1KSInsuredRECE�VE� BY'rol Agency
3830 PILOT KNOB ROAD I EAGAN, MN 55122-1810
(651) 675-5675 1 FAX: (651) 675-5694
Plan Submittal: eplans(acityofeaaan.com
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For Office Use I
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Date Received:
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I Staff:
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SEPTIC SYSTEM MAINTENANCE FORM
Date Pumped: 71 /
Z
Site Address: SJR
Owner's Name: 7 707VO S V -
Owner's Address (if different from site):
# of Tanks Pumped: Total Gallons
Pumped:
O+A/e / i
2600
s/ 2 /- 15'3
Owner's Email: (aO (�j (P MSA . Cd P1 Owner's Phone #: ip.5 V j Li
Maintainer's Name: /if v•Q {- SP y/ r Se ry c P , License Number: Z-- q 1,
Private Residence: X Commercial
Condition of Baffles:
Pumped Through:
Comments:
Disposal Location:—� & IV
Type of Tanks: / � " t L /e t/eWb Ze of Tanks:
Effluent Sewage Discharge: Yes: No:
Name of Person Completing Form: 6 D � Date: /Q Z Z 0 Z
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on the City's website atwww.ci ofeagan.com/subscribe.
Please submit completed forms to the Building Inspections Division via mail, fax or email.