820 ONeill Dr - Septic Maintenance Form 2022-07-27�..At EAGA N
3830 PILOT KNOB ROAD I EAGAN, MN 55122-1810
(651) 675-5675 1 FAX: (651) 675-5694
Plan Submittal: eclansia-�cityofeagan.com
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For Office Use
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Date Received: I
I I
I I
I Staff: I
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SEPTIC SYSTEM MAINTENANCE FORM
Date Pumped: > .1.Z # of Tanks Pumped:
Site Address: g�t:� L� �/�� ///cr��4�;�AN
Total Gallons
Pumped: /S_0_0
1"/V
Owner's Name: L�Cf�.�C�
c�%1!I(/C/5
®,lel//
Owner's Address (if different from site):
Owner's Email:
ot(/Ej�/RS/ A?/4(L f eZV4
Owner's Phone #:f
Maintainer's Name:/�r�J!'L�•�iE'iL
�Pi2l%!c!
License Number:
Private Residence:
y� Commercial: Disposal Location:
Condition of Baffles:
Type of Tanks:
Size
of Tanks:
Pumped Through:
Effluent Sewage Discharge: Yes:
No: X
Comments
Name of Person Completing Form: r E/ Date: /�7 2� Z.Z
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Please submit completed forms to the Building Inspections Division via mail, fax or email.
A
F1
L -i
CHECK
CASH
NAME
ME
ADDRESS
PUMPED AND BACKFLUSHED:
5325 MANNING AVE, SO., AFTON, MN 55001
Family Owned Business Since 1976
LANA MEYER
E 5" `fv' 45
21
i , 9-01 n a2
Liquid Waste Pumped - Portable Toilet and Sink Rental
D VISA
CHARGEI DO C A ""D C
DATE
Cesspool
Holding Tank
Lift Station
Distribution or Junction Box
Extra Backflushing
feet of hose (Extra charge for over 100 feet of hose)
7 7_11
Washington County Fee
PUMPED:
Sandtrap
Sump
Other:
Weekend or Evening Charge
RECEIVED BY
TOTAL GALLONS:
Pumped through manhole or inspOff 'p pe
Septic tank:., Precast -Block - Plastic
Overflow tank: ---Precast - Block - Plastic - Unknown
Condition of baffle :,:1600" d", Repair Neaded, or Unknown
Drainfield: Mounid, trench, or Unknown
Effluent surface discharge: Yes or/No?
Lift Station: Yes
or No
Comments.
N�m
TOT/1q,
a
Ar
MEADER
U126.1a ME
M.14 Rama
Licensed - Bonded - Insured
Licensed by the
Minnesota Pollution Control Agency
RA1,W:G