830 ONeill Dr - Septic Maintenance Form 2021-12-01EAGAN
3830 PILOT KNOB ROAD I EAGAN, MN 55122-1810
(651) 675-5675 I FAX: (651) 675-5694
Plan Submittal: eolans(a cityofeagan.com
Date Pumped:
(,Site Address:
Owner's Name:
For Office Use
Date Received:
Staff:
SEPTIC SYSTEM MAINTENANCE FORM
op
ti,
vizi Total Gallons v 1/# of Tanks Pumped.. ��Q D I'" )3APumped: p-
8N,30 d 'AV D r v Ef Q'1,1 i!4 // 5 /z 1-- /539
-1-1 /1-&ty Ali
Owner's Address (if different from site):
Owner's Email:
n0-1 0/-4.C" /nsn.(rrv)
Maintainer's Name:
X ° St fat. C
Private Residence: Commercial: Disposal Location:
,SlititeA) Sueict.
Owner's Phone #:
Condition of Baffles: LuA n t Y\
Pumped Through: 5t(Amd
Comments:
License Number:
.SJ - 5-7Z
L 9/s
%Spt1L
Type of Tanks: 2, et /Li/001S Size of Tanks:
Effluent Sewage Discharge: Yes:
/M O I.Cln
No:
bob j4dlifd 4,wi' JA_Dict..) pevry ' -3 Lv
I fia !u, .'u 'tam, I)tL4 L hid-zi- 30 r
Name of Person Completing Form: .,4ft D -a Date: 14/Z Z
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Please submit completed forms to the Building Inspections Division via mail, fax or email.