781 Hackmore Dr - Sepitc Maintenance 11/16/22 (2)EAGAN
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3830 PILOT KNOB ROAD I EAGAN, MN 55122-1810
(651) 675-56751 FAX:
(651) 675-5694
Plan Submittal: eolansAcitvofeagan.com
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For Office Use
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Date Received: I
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I Staff: I
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SEPTIC SYSTEM MAINTENANCE FORM
Date Pumped: `j / �� /aD2, # of Tanks Pumped:
Site Address
:
Owner's Name' // Z
Owner's Address (if different from site)):
Owner's Email: eGi a-,I-e,1 l%
Total Gallons , nn �l
Pumped:
>a Al A) 6-SI �7-3
Owner's Phone #: 6/,Z -R1- ,M4
Maintainer's Name: /f'/l��G/�- �r� ✓���G� License Number:
Private Residence: Commercial: Disposal Location:
Condition of Baffles: /Nmy4*A) Type of Tanks: % Size of Tanks:
Pumped Through: AVJA5D97I600 AP15 Effluent Sewage Discharge: Yes:
Comments:
No:
Name of Person Completing Form: i�1ri �J%'r�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.cltvofeagan.com/subscribe.
Please submit completed forms to the Building Inspections Division via mail, fax or email.