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4020 Blackhawk Rd - Septic Maintenance Form 2024-09-163830 PILOT KNOB ROAD I EAGAN, MN 55122-1810 (651) 675-5675 1 TDD: (651) 454-8535 J FAX: (651) 675-5694 buildin ins ections cit ofea an.com t F`---J-------- For Office Use I I I I Date Received: i I 1 Staff: --------------------- 1 SEPTIC SYSTEM MAINTENANCE FORM Date Pumped: {' 0 -2(1 Site Address: L-1b2-ke ir j Owner's Name: Owner's Address (if different from site): Owner's Email: Maintainer's Name: Private Residence: Condition of Baffles Pumped Through: Comments: S u<4, # of Tanks Pumped; Total Gallons Pumped; A Owner's Phone #: License Number: Commercial: Disposal Location:1� �cx�iCs cl o�� Type of Tanks: Z Effluent Sewage Discharge: Size of Tanks: � I � Yes: No; A You may subscribe to receive an electronic notification from the City of proposed ordinances by signing up for an email update on the City's website at \"ww-cityofeagan.com/sUbscribe. Please submit completed forms to the Building Inspections Division via mail, fax or email.