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4395 South Robert Tr - Septic Maintenance Form 2021-05-11 --------------------- For Office Use �i 1 Date Received: EAGAN I Staff: I .^ I--------------------1 3830 PILOT KNOB ROAD I EAGAN, MN 55122-1810 (651)675-5675 1 FAX: (651)675-5694 Plan Submittal:eplans(a cityofeagan.com SEPTIC SYSTEM MAINTENANCE FORM Date Pumped: s4 #of Tanks Pumped: Total Gallons Pumped: Site Address: r IL 7—L!z--> Owner's Name: �J s� � 1 '5�56) l Owner's Address if0---different from site): � � iiE Owner's Email: (> Owner's Phone# iC J l� CY Maintainer's Name: /G•� License Number: Private Residence: Commercial: Disposal Location: Condition of Baffles: Type of Tanks: Size of Tanks: Pumped Through: Effluent Sewage Discharge: Yes: No: Comments: Name of Person Completing Form: Date: You may subscribe to receive an electronic notification from the City of proposed ordinances by signing up for an email update on the City's website at www.cityofeagan.com/subscribe. Please submit completed forms to the Building Inspections Division via mail,fax or email. t7 t= m O n 0 'C3 —1 m Q Cf) Cf) -0 S� (T# �_ -e p < CD (� C) * C Al C Al N ti 0 CD < CD, A CD r+ 0 CD 'C3. C x m +. : CD Z3 mT. C!? C3 U) pD C2 n �T m N -0 t3 p •0 57' 0 0 CL 's� p T til CD n o N p p `' mCD c � z c s C6_e ..f17 CQ =3 � - G) .w , Cr. (� CD X 7l e ri S CD 3 d[ZJ s 0 {y7 p -qx i CD z T1l �. c r., � C Z} T D :a CD _ ; C cn pl - O Op N np`M"- �� _- CD (D Z p O m W C 0 Z3 CCDN C5D -:a ' O n Z o t4 � r > Y o D < ® Cl) "�x su m 0 12 egor�0n N ssi.. `n W o 3 Q R. S.E MHIJ i +d O _ 7� O 0 0 3 `W m CD >®i 2 r0-, ..