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
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For Office Use I
I I
I Date Received: i
I 1
Staff:
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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
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Please submit completed forms to the Building Inspections Division via mail, fax or email.