2145 Kings Rd - Septic Maintenance Form 2022-10-25---------------------
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a% a� sr �r I Date Received:
EAGAN ''�� •rte/
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3830 PILOT KNOB ROAD I EAGAN, MN 55122-1810
(651) 675-5675 1 FAX: (651) 675-5694
Plan Submittal: eplansacityofeaaan.com
SEPTIC SYSTEM MAINTENANCE FORM
Date Pumped: 0®I a% # of Tanks Pumped: C� Total Gallons
Pumped: IpSyy
Site Address: �I I ; � nyl S 2OCICA
Owner's Name:
Owner's Address (if different from site):
Owner's Email: 011A Owner's Phone #:
, �\ 1
Maintainer's Name: Vi!,t Ilhi� License Number:
Private Residence:_ Commercial: Disposal Location: fim
RAI �
Condition of Baffles: � 1Y1��1,�W � Type of Tanks: �V . Size ze o Tanks:
Pumped Through:Q_4� Effluent Sewage Discharge: Yes: No:
Comments:
Name of Person Completing Form: �� Date:
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Please submit completed forms to the Building Inspections Division via mail, fax or email.