1284 Carriage HIlls Dr - Septic Maintenance Form 2023-05-23♦ ♦ i
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EAGAN_.0
3830 PILOT KNOB ROAD I EAGAN, MN 55122-1810
(651) 675-56751 FAX: (651) 675-5694
Plan Submittal: eplans(d�cityofeanan.com
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For Office Use
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I Date Received:
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I Staff: I
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SEPTIC SYSTEM MAINTENANCE FORM
Date Pumped: _-2- :7— . �L,
Site Address:
# of Tanks Pumped: / Total Gallons
Pumped: C S
moi'! _per Ar, tLS' 8 -.
Owner's Name: � Chi'
Owner's Address (if different from site):
Owner's Email:
Owner's Phone#: IDJI-(�/fid,
Maintainer's Name. a-- ke ci4 License Number: �\U�
Private Residence: ✓ Commercial: Disposal Location:
Condition of Baffles: '-LL ry 3-P h/ Type of Tanks: t ' - Size of Tanks: /% 579
Pumped Through: �^i fa -0-- Effluent Sewage Discharge: Yes: No:
Comments:
Name of Person Completing Form: LD Date: U 1-71
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Please submit completed forms to the Building Inspections Division via mail, fax or email.