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4135 South Robert Tr - Septic Maintenance Form 2023-02-28 --------------------- For Office Use �f 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:eplansacityofeagan.com SEPTIC SYSTEM MAINTENANCE FORM Date Pumped: �f Z `� #of Tanks Pumped: Total Gallons all Pumped: ®� Site Address: _'1136— Ao hh.- 4, Owner's Name: V tt G V,4—I2 p Lit t �_w'LC� .• Owner's Address(if different from site): Owner's Email r Fp S c C I Ua d4a pp L a Owner's Phone#: ( 2 b C-/v1 Maintainer's Name: L D 41 e S License Number: Private Residence: Commercial: Disposal Location: �� w Condition of Baffles: 1J� Type of Tanks: �l�C`�i Int Size of Tanks: rao, Pumped Through: Ak \ w`\^^t- ViCOM9, Effluent Sewage Discharge: Yes: No: VAComments: �0 Name of Person Completing Form: ( / V 1 Date: ✓ V You may subscribe to receive an electronic notification rom the City of proposed ordinances by signing up for an email update on the City's website at www.citvofeacian.com/subscribe. Please submit completed forms to the Building Inspections Division via mail,fax or email.