4640 dodd Rd - Septic Maintenance Form 8/14/23EAGAN
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3830 PILOT KNOB ROAD I EAGAN, MN 55122-1810
(651)675-56751 FAX:(651) 675-5694
Plan Submittal: eolansacitvofeaaan.com
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For ice 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 �_ 'L - # of Tanks Pumped:
Site Address: It �0 4
Owner's Name: 'U k- s Q, f 0 Y S ti, a.n
Owner's Address (if different from site):
Owner's Email:
W
Total Gallons
Pumped: 6 0 0
Owner's Phone #:
Maintainer's Name: 1" \ # uy- Jewtr SCYV cc License Number: L `I b
Private Residence: Commercial: _ _ _ Disposal Location: cjt P2.J \ r e3{ mex'i Q13w't
( )Soo a
Condition of Baffles: V 0 04 Type of Tanks: f, Size of Tanks: % o0 0
Pumped Through: rv%; "of A -
Comments:
Effluent Sewage Discharge: Yes: No: ✓
Name of Person Completing Form: 1) , 11 4 ATF- -r Date: _ _00 - I 1 ' 1. S
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Please submit completed forms to the Building Inspections Division via mail, fax or email.