870 Lakewood Hills Rd - Septic Maintenance Form 2022-10-05AmbkL-
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City 0f Ea,,u
3830 Pilot Knob Road
Eagan MN 55122
Phone: (651) 675-5675
Fax: (651) 675-5694
Email: commdevelopment(a)cityofeagan.com
Date Pumped
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For Office Use
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IDate Received: 2 2 I
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I Staff:
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SEPTIC SYSTEM MAINTENANCE FORM
to -S - 2Z
# of Tanks Pumped: I _ Total Gallons Pumped: 'Jck)
Site Address: 2 -7b 1-416woU" 14 r ? tS &4t("
Owner's Name: 69 7-%c- J 1-4 61 S
3wner's Address (if different from site): p �j' 9
Maintainers Name: 1 F e,,jA-&a s� Pyr C QUMP/License Number: L �4
Private Residence: _ Commercial: Disposal Location: ff L /�' ` (-
Condition of Baffles: ' Type of Tanks: 4'c CEJ T Size of Tanks: 1(90 6
Pumped Through: °3J{ t too te' Effluent Sewage Discharge: Yes: No.
Comments:
Please submit completed forms to the Building Inspections Division via mail, fax or email.