4860 Biscayne Ave - Septic Maintenance Form 2022-03-25411�
City of Eap
3830 Pilot Knob Road
Eagan MN 55122
Phone: (651) 675-5675
Fax: (651) 675-5694
Email: commdevelopment(@-cityofeagan.com
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For Office Use I
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I Date Received:
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I Staff: I
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SEPTIC SYSTEM MAINTENANCE FORM
Date Pumped: �_ a5 __ 1-)-Q)—
Site Address: 2) Ca
# of Tanks Pumped:
Owner's Name: Q3,(. c�c)y S i �, —�G c; S
Owner's Address (if different from site):
Total Gallons Pumped: 1(3Qcj
Maintainer's Name: \—CO " 5
QZu--,RS, 'rt e" y
SQ0i C.. License Number:
Private Residence: Commercial:
Y Disposal Location:
Condition of Baffles:
Pumped Through:
Comments:
Type of Tanks: C_ Size of Tanks: �C<Lc�j
Effluent Sewage Discharge: Yes: No: X
Please submit completed forms to the Building Inspections Division via mail, fax or email.