4020 Blackhawk Rd - Septic Maintenance Form 2021-09-16 ---------------------
s For Office Use
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�0 i Date Received:
EAGAN I I
I Staff: I
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3830 PILOT KNOB ROAD I EAGAN, MN 55122-1810
(651)675-5675 1 FAX: (651)675-5694
Plan Submittal:eplans cacityofeagan.com
SEPTIC SYSTEM MAINTENANCE FORM
�y Total Gallons /
Date Pumped: ��7 /�i #of Tanks Pumped: ,� Pumped:
Site Address: 02D � ` ,l �a"\nn 5, I�
Owner's Name:
Owner's Address(if different from site): [� n1 �/�
Owner's Email: �� Ll w, - 1"1 l�1 •C C) f r ! Owner's Phone#: to 51-303 l g�
Maintainer's Name: R 1 k License Number: �(� 7�3
Private Residence: X Commercial: Disposal Location: 1{' CCw ' 1 ��O ��<z✓1
Condition of Baffles: cid Type of Tanks: Ce-5 P r,-1 Size of Tanks:
Pumped Through: S p�Gt�G'►� �� �'(� Effluent Sewage Discharge: Yes: No: X
Comments:
Name of Person Completing Form: er Date:
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