3366 Hwy 55 - Septic Maintenance Form 2022-04-053830 PILOT KNOB ROAD j EAGAN, MN 55122-1810
(651) 675-56751 FAX: (651) 675-5694
Plan Submittal: eplansCDcityofeaoan.com
---------------------
t=or Office Use t
t Date Received:_j j / �2,o t
�'r��� t
�llififiL., t
--------------------
SEPTIC SYSTEM MAINTENANCE FORM
Date Pumped:'} # of Tanks Pumped: Total Gallons
c� Pumped:
Site Address: 7,,F.
,j
Owner's Name: 1'.J ? j/1
Owner's Address (if different from site):
Owner's Email
Maintainer's Name:
Private Residence:
Condition of Baffles:
Pumped Through:
Comments:
30n -
Owners Phone #: 6 62 ' 42 � -72.2,;!6
License Number:
Commercial: Disposal Location:
600 Type of Tanks: 'C Size of Tanks: G g(
k u Effluent Sewage Discharge: Yes: No:
Name of Person Completing Form:
Date:
You may subscribe to receive an electronic notification from the City of proposed ordinances by signing up for an email update
on the City's website at www.citvofeagan.com/subscribe.
Please submit completed forms to the Building Inspections Division via mail, fax or email.