4135 South Robert Tr - Septic Maintenance Form 2023-02-28 ---------------------
For Office Use
�f 1 Date Received:
EAGAN
I Staff: I
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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
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Please submit completed forms to the Building Inspections Division via mail,fax or email.