995 Cliff Rd - Septic Maintenance Form 2023-11-02EAGAN
3830 PILOT KNOB ROAD I EAGAN, MN 55122-1810
(651) 675-5675 1 FAX: (651) 675-5694
Plan Submittal eplans(a?citvofeagan.com
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For Office Use
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Date Received:
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I Staff: I
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SEPTIC SYSTEM MAINTENANCE FORM
Date Pumped: / �� �2 3 # of Tanks Pumped
Site Address: l j l �/-&�_ i L a
Owner's Name: 41&"- `
Owner's Address (if different from site):
Owner's Email: Al"X
Total Gallons 1566
Pumped:
M /L�
-123
psi y� y- yg V�
Owner's Phone #: —6-5-1 Y5 1 _ 419 `I4
Maintainer's Name: ' ' /eye ��y�G�'- License Number:
Private Residence: V Commercial: Disposal Location:
Condition of Baffles:
Pumped Through:
Comments:
Type of Tanks:
Size of Tanks:
Effluent Sewage Discharge: Yes:
Oot- a uaz-bi,&
0
No:
Name of Person Completing Form:��lr�Q2� �'� dL�iLP� Date: /2 3
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on the City's website at www.citvofeauan.com/subscribe.
Please submit completed forms to the Building Inspections Division via mail, fax or email.
eyer-a
PO BOX 40
AFTON, MN 55001
55
ewer 4
Family Owned Business Since 1976
ervice
Q
(651) 459-0162
www.MeyerSewer.com
CASH
CMAR E
CREDIT CARD CHARGES
PLEASE CALL
DATE( j
l E ,,.% J
r�0�
CKFLUSHED:
Cesspool
Holding Tank
Sump
Cleaned Filter
Used Crust Buster to break up thick crust
Extra Backflushing
�� feet of hose (Extra charge for over 120 feet of hose)
County Fee or City Fee
Disposal Fee
CRIER REPAIRS:
Weekend or Evening Charge
TOTAL GALLONS:
r TOTAL r .'
COMMENTS: <_
B&
iEr
RECEIVED BY: Llwneod•Bonded •/neured
I'censeo by the
Mlnne�,nlu Pollution Contrail Agenvy
PeiNo: