861 Lakewood Hills Rd - Septic Maintenance Form 2022-04-2941�
City of EafiGH�
3830 Pilot Knob Road
Eagan MN 55122
Phone: (651) 675-5675
Fax: (651) 675-5694
Email: commdevelopment(aD_cityofeagan.com
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For Office Use
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I Date Received:
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I Staff:
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SEPTIC SYSTEM MAINTENANCE FORM
Date Pumped: # of Tanks Pumped: Total Gallons Pumped:
SiteAddress:
Owner's Name:li:CAVl-2 s 3
Owner's Address (if different from site):
Maintainer's Name: L� � , ewe--� , YJ4 �: L License Number: so;�—
Private Residence: Commercial: Disposal Location: (� �`C\V� \ 3;aV YY\ w,�
Condition of Baffles: `V\�U< ' Type of Tanks: r Size of Tanks: U( }
Pumped Through: VGYI Cwt
Comments:
Your copy of the
submitted form.
Effluent Sewage Discharge: Yes: No:
Please submit completed forms to the Building Inspections Division via mail, fax or email.