4135 South Robert Tr - Septic Maintenance Form 2022-05-27401�
City of NOR
3830 Pilot Knob Road
Eagan MN 55122
Phone: (651) 675-5675
Fax: (651) 675-5694
Email: commdevelopment(a)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: rJ ' a� - a� # of Tanks Pumped: Total Gallons Pumped: V�y
Site Address:
Owner's Name: V QL\ bk01&,+0XV Wk
Owner's Address (if different from site):
Maintainer's Name: �GC�c,1,� S S�ue�! i�Y��h '� (� License Number: `1
Private Residence: Commercial: Disposal Location: m D,\Y'(Z-,
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Condition of Baffles: N l Q. Type of Tanks: �Q� *kyn X Size of Tanks: L OUO `E �dOC�
Pumped Through: k n's Effluent Sewage Discharge: Yes: No:
Comments:
Please submit completed forms to the Building Inspections Division via mail, fax or email.