2750 Lexington Ave - Septic Maintenance 07/11/24EAGAN
3830 PILOT KNOB ROAD I EAGAN, MN 55122-1810
(651)675-5675 1 FAX:(651) 675-5694
Plan Submittal: eolans(@citvofeagan.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: 1 - 11 _ l y # of Tanks Pumped
Site Address: 11
Total Gallons
Pumped:
1000
Owner's Name: C-Vossl_oyntrY FreiQi1t Sb`Vt10ytg
Owner's Address (if different from site):
Owner's Email: + Owner's Phone #:
Maintainer's Name: I" \ eI e y J 2,nJ [- EY`11 c-e, License Number:
Private Residence: (Commercial: ✓ Disposal Location: Sk F k,) 1 umV. p- M 0- n'i P l an
Condition of Baffles: V D ecl Type of Tanks: 5 pp}" C� Size of Tanks: 1000
Pumped Through: Man\no\P Effluent Sewage Discharge: Yes: No:
Comments:
Name of Person Completing Form: CYtr-,9 v l 1Anl3r Date: -I - l\ - it
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Please submit completed forms to the Building Inspections Division via mail, fax or email.