706 Lone Oak Rd - Septic Maintenance Form 2021-05-04City of Ea�all
3830 Pilot Knob Road
Eagan MN 55122
Phone: (651) 675-5675
Fax: (651) 675-5694
Email: commdevelopment{c�citvafeagan.com
For Office Use
❑ate Received:
Staff.
SEPTIC SYSTEM MAINTENANCE FORM
Date Pumped: '/"Y ! 2 I ## of Tanks Pumped: 1 Total Gallons Pumped: / S 6 b
Site Address: .-7 ()c (6'k OaK K k r) E &'j &, 7/J S5?.?-/
Owner's Name: ,J Ohin 1/0rY12 /.�
Owner's Address (if different from site):
Maintainer's Name:
License Number:
c2q 9R
Private Residence: _ Commercial: Disposal Location: ��i�ll�� �Css�� �� Tod-film-F(4m+
of Baffles: (An Lnbto Type of Tanks: Size of Tanks: ), CO°
^� Pumped Through: Effluent Sewage Discharge: Yes: No: V
Comments:
Please submit completed forms to the Building Inspections Division via mail, fax or email.