640 Lone Oak Rd - Septic Maintenance Form 2018-11-194011�
Cityof Eap
3830 Pilot Knob Road
Eagan MN 55122
Phone: (651) 675-5675
Fax: (651)675-5694
Email: commdevelopment()citvofeagan com
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For Office Use I
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Date Received: I
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I Staff:
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SEPTIC SYSTEM MAINTENANCE FORM
Date Pumped: u I /IF # of Tanks Pumped: 21 Total Gallons Pumped: ,I q
Site Address: tr `/ () LoPq Oath
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Owner's Name:
Owner's Address (if different from site):
Maintainer's Name: L \ li 1�,'['"r ��1�V I l� License Number: ��
Private Residence: Commercial: Disposal Location: Ale y o
Condition of Baffles: t U Type of Tanks: tr'� /[_ Size of Tanks: 1700
Pumped Through: [fle Effluent Sewage Discharge: Yes: No:
Comments:
Please submit completed forms to the Building Inspections Division via mail, fax or email.
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