578 Michigan Ct - Septic Maintenance Form 2022-11-03 ---------------------
For Office Use
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Date Received:
EAGAN I I
I Staff: I
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3830 PILOT KNOB ROAD I EAGAN, MN 55122-1810
(651)675-56751 FAX: (651)675-5694
Plan Submittal: eplans(aDcityofeagan.com
SEPTIC SYSTEM MAINTENANCE FORM
Date Pumped: 1 (� � 3V� #of Tanks Pumped: 41 PumTotapGallons V� U
d- Pumped:
Site Address: r J 7 � M CO J C'CA V) C U A Y t
Owner's Name:
Owner's Address(if different from site): `
Owner's Email: Owner's Phone#: --)W J,— --)W-)1 -7-7
Maintainer's Name: �CA IZ-UC ,S �- License Number:
Private Residence: k Commercial: Disposal Location:
Condition of Baffles. lU "� Type of Tanks: \)h C)� U(Aize of Tanks: �L
Pumped Through:
t` ( �� Effluent Sewage Discharge: Yes: No:
Comments:
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Name of Person Completing Form: Y � � Date: I 1 I� R o�
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Please submit completed forms to the Building Inspections Division via mail,fax or email.