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:
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on the City's website at www.cityofeagan.com/subscribe.
Please submit completed forms to the Building Inspections Division via mail,fax or email.
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