912 Lakewood Hills Rd - Septic Maintenance 7/18/24• • • • /
EAGAN
3830 PILOT KNOB ROAD I EAGAN, MN 55122-1810
(651) 675-5675 1 FAX: (651) 675-5694
Plan Submittal: eplansCo-_)cityofeagan.com
---------------------
For Office Use
I I
Date Received:
I I
I I
I Staff: I
I I
---------------------
SEPTIC SYSTEM MAINTENANCE FORM
Date Pumped: L�) ` i/ W
Site Address:
Owner's Name:
Owner's Address (if different from site):
Owner's Email:
# of Tanks Pumped: Total Gallons C / 1
2- Pumped: V V
Owner's Phone #:
Maintainer's Name: LL � "C_�i� License Number: 0 21t
Private Residence:_ Commercial: Disposal Location: a�-jn/�� r� ��Ti CJ�+1 ► 1.t
Condition of Baffles: Type of Tanks: Size of Tanks:
Pumped Through:�� l�l
Comments:
Effluent Sewage Discharge: Yes: No: /V
Name of Person Completing Form: Date:
You may subscribe to receive an electronic notificatio 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.