750 Hackmore Dr - Septic Maintenance Form 2022-03-05EAGAN
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3830 PILOT KNOB ROAD I EAGAN, MN 55122-1810
(651)675-5675 FAX: (651) 675-5694
Plan Submittal: epIansCo)citvofeacan.com
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For Office Use
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Date Recetved:
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I Staff:
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SEPTIC SYSTEM MAINTENANCE FORM
Date Pumped: #of Tanks Pumped: Total Gallons
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Site Address: 7.5-0 yfQcl( rvj p� I/ R C r� PV U
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Owners Name:
Owner's Address (if different from site):
Owner's Email: Opp( Gcoln cgS . n`l Owner's Phone#:
Maintainers Name: License Number.
Private Residence: Commercial: Disposal Location:
Condition of Baffles: .F'in ndcYn/ Type of Tanks:r"'. Size of Tanks:
Pumped Through: Effluent Sewage Discharge: Yes: No: r
Comments:
Name of Person Completing Form:
Date:
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Please submit completed forms to the Building Inspections Division via mail, fax or email.