3344 Sibley Memorial Hwy - Septic Maintenance Form 2024-05-20E A G A N
3830 PILOT KNOB ROAD I EAGAN, MN 55122-1810
(651) 675-5675 1 FAX: (651) 675-5694
Plan Submittal: eplans((bcitvofeagan.com
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For Office Use II
I
I Date Received: I
I
I Staff: I
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SEPTIC SYSTEM MAINTENANCE FORM
Date Pumped:-5-_;L0 - d0.2q # of Tanks Pumped:
Site Address:
Owner's Name:
33'1 y S
0
Owner's Address (if different from site):
Owner's Email: A�V�7 DD� C)
Total Gallons
Pumped: 0�? C <-e�en
6) �j 7 53-I21
Owner's Phone #: 6) 2 - 6 Ltq g y yy
Maintainer's Name: „f ��,,/�,/ License Number:
Private Residence: �_ Commercial: Disposal Location: ,L
Condition of Baffles: (;ar Type of Tanks: ✓ ✓ Size of Tanks: /5Ca0^ ZCge%
Pumped Through: M4 ,X^4.5 Effluent Sewage Discharge: Yes: No: M,
Comments:
Name of Person Completing Form: �V, 1 (5,41 W a )he.Y Date: J -to - L 1
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on the City's website at www.citvofeagan.com/subscribe.
Please submit completed forms to the Building Inspections Division via mail, fax or email.
PO BOX 40
AFTON, MN 55001
Family Owned Business Since 1976
www.MeyerSewer.com
CNECx
cA.
NAME
MpAESS
PUMPED AND BACKFLUSHED:
cTa
7
Tan
Pump (Lift) Tank
Cesspool
Holding Tank
Sunup
aned Filter
UseC Crust Buster to break up thick crust
jc
�ye'3
Extra Backflushing
1,,20 feet of hose (Extra charge for over 120 feet of hose)
County Fee or City Fee
Disposal Fee
f� /
OTHER REPAIRS:zlyte
Weekend or Evening Charge
TOTAL GALLONS:
COMMENTS:
4
�L. GGG'.
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un+,aw xwn,e
Minn6eo4 Poovtion.^,o2rol Aymicy
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