885 Lakewood Hills Rd - Septic Maintenance Form 09/27/20233830 PILOT KNOB ROAD I EAGAN, MN 55122-1810
(651) 675-5675 1 FAX: (651) 675-5694
Plan Submittal: ealansecitvofeaoan.com
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For Office Use
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I I
I
Date Received:
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I Staff: I
II
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SEPTIC SYSTEM MAINTENANCE FORM
Date Pumped: 4 2rJ 2 # of Tanks Pumped: �, Total Gallons
Pumped:
Site Address: Z95 IAREW O oh H 6 LLs R ,
ffAsAN1 heV Q- �;'l--20
Owner's Name: �� �� G
IToo
Owner's Address (if different from site):
EAGAN
�1
Owner's Phone #:
3830 PILOT KNOB ROAD I EAGAN, MN 55122-1810
(651) 675-5675 1 FAX: (651) 675-5694
Plan Submittal: ealansecitvofeaoan.com
---------------------
For Office Use
I I
I I
I
Date Received:
I I
I Staff: I
II
---------------------
SEPTIC SYSTEM MAINTENANCE FORM
Date Pumped: 4 2rJ 2 # of Tanks Pumped: �, Total Gallons
Pumped:
Site Address: Z95 IAREW O oh H 6 LLs R ,
ffAsAN1 heV Q- �;'l--20
Owner's Name: �� �� G
IToo
Owner's Address (if different from site):
Owner's Email:
Owner's Phone #:
/�
65l ` 47 4 32�
b L
�'-�'y 5FAVtNumber:
Maintainer's Name:
License
Private Residence:
Commercial:
Disposal Location:
—
Condition of Baffles:
Type of Tanks:–� Size
of Tankj;
Through:
t/AWW ROY,
Sewage Discharge: Yes:
No:
Pumped
Effluent
Comments:
Name of Person Completing Form: g tljii `, Date:
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on the City's website at www.citvofeanan.com/subscribe.
Please submit completed forms to the Building Inspections Division via mail, fax or email.
PO BOX 40
kleyer—o AFTON, MN 55001
Sewer 6 - Family Owned Business Since 1976
Service (651) 459-0162
www.MeyerSewer.com
CHECK /^
ly+l�
minnasoia
CASH
CHARGE
CREDIT CARD CHARGES
PLEASE CALL
DATE/j
7
NAME
ADDRESS
PUMPED AND BACKFLUSHED:
p is Ink
ve o Tan
Pump (Lift) Tank
Cesspool
Holding Tank
Sump
Cleaned Filter
Used Crust Buster to break up thick crust
Extra Backflushing
� 0
%�D�l
feet of hose (Extra charge for over 120 feet of hosel,
County Fee or City Fee
Disposal Fee
OTHER REPAIRS:
Weekend or Evening Charge
TOTAL GALLONS: 15Q� TOTAL
COMMENTS:
86
T
Licensed • Bonded • Insured
RECEIVED BY: Licensed by the
--ii- -- agency
�28� 7 a