4395 South Robert Tr - Septic Maintenance Form 2024-04-284 I f
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EAGAN
3830 PILOT KNOB ROAD I EAGAN, MN 55122-1810
(651) 675-5675 1 FAX: (651) 675-5694
Plan Submittal: eplans(a)cityofeaaan.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: Y12-5; v / # of Tanks Pumped
Site Address:
Owner's Name: f---, ^�
Total Gallons
// Pumped:
Owner's Address (if different from site):Z-0� �� Q77
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Owner's Email s j C � Owner's Phone #: �QiZ 719
3T
Maintainer's Nam G �� [`2%icense Number:
Private Residence: Commercial: Disposal Location:
Condition of Baffles: Type of Tanks: Size of Tanks:
Pumped Through: Effluent Sewage Discharge: Yes: No:
Comments:
Name of Person Completing Form:�� c� Date:
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 www.citvofeagan.com/subscribe.
Please submit completed forms to the Building Inspections Division via mail, fax or email.
SQHL0MM4ERV10EejLC
17560 Northfield Blvd
Hasfings, MN 55033
651-459-3718
office@schlomkaservices.com
www.schlomkaserVices.com
BT
ILL,,
Myron Hanson
4015 Dodd Rd
Eagan, MN 55123
Invewe
DATE,
NV idE
32041 12/05/2023 01/04/2024 Net 30
TEAM. . . . . . . . .
ji
12/05/2023 PT
1200 Gallons
THANK YOU for your 0usinessl
ANY UNPAID BALANCE OVER 30 DAYS FROM DATE OF INVOICE WILL
BE SUBJECT TO A FINANCE CHARGE AT THE RATE OF 1.5*/* PER
MONTH (iso% PER YEAR). We also take Mastercard, Visa, American Express
& Discover. Carl PF"
1939
MR, 1 560 Northfield Blvd.
Hastince, MN 55033
(651 459-3718
JADDRE8S
P,O.D. I CHARGE I ON ACCT IMDSF--RET-01
275.00,
BALANCE DUE
275.00,