733 Bradford Pl - Septic Maintenance 6/4/24\ � • I j IEAGAN
n
3830 PILOT KNOB ROAD I EAGAN, MN 55122-1810
(651) 675-5675 1 FAX: (651) 675-5694
Plan Submittal: eplans(a�cityofeagan.com
Date Pumped:
Site Address:
Owner's Name:
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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
Z # of Tanks Pumped: �% Total Gallons
UNIPumped:
-en
V vn
ueOv
Owner's Address (if different from site):
Owner's Email: Owner's Phone #:
Maintainer's Name: ( �j( �License Number:
Private Residence: Commercial: Disposal Location: lcyq j� k V�UWUt/WWTye tV4
Condition of Baffles: Type of Tanks:Size of Tanks:
Pumped Through: VVNV t 1 1 wau Effluent Sewage Discharge: Yes: No:
Comments:
Name of Person Completing Form: ,�� i- t M'►1�`� Date: 6) IW16? f
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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.