550 Diffley Rd - Septic Maintenance Form 2021-08-18EAGAN
3830 PILOT KNOB ROAD 1 EAGAN, MN 55122-1810
(651) 675-5675 j FAX: (651) 675-5694
Plan Submittal: eplanscrtyofeagan.com
Date Pumped:
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For offs
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Date Received:
Staff:
....................
SEPTIC SYSTEM MAINTENANCE FORM
Site Address: 5 0 Diccilej
Owner's Name:
Owner's Email:
Maintainer's Name:
Private Residence:
Condition of Baffles:
Pumped Through:
Comments:
# of Tanks Pumped:
Pottik
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Owner's Address (if different from site):
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Total Gallons
Pumped:
55113
toob
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Owner's Phone #: k 51 7B5i 6 i1
License Number
Commercial: Disposal Location: �Yi1pyNe(r
.04An viiess
Type of Tanks:
pce ccrtsr
Size of Tanks:
wwiP
Effluent Sewage Discharge: Yes:
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No: K
Name of Person Completing Form:
H h t#1 e:.� rfre/Iyj
Date:
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• the Building Inspections Division via mail, fax or email.
Please submit completed forms to g