894 Lakewood Hills Rd - Septic Maintenance Form 10/22/2024I / IEAGAN
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3830 PILOT KNOB ROAD I EAGAN, MN 55122-1810
(651) 675-5675 1 FAX: (651) 675-5694
Plan Submittal: eeplans(acitvofeaoan.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:(' # of Tanks Pumped / 4 —
Site Address:
Owner's Name: ),)I's AQ- a .� ✓L, C --
Owner's
Owner's Address (if different from site):
Total Gallons
Pumped:
M.
& S% --
Owner's Email:
Maintainer's Name: License Number:
Private Residence:_ Commercial: Disposal Location: ,i�-{jtr9 4-
5
Condition of Baffles: `� Type of Tanks: .s�— Size of Tanks: jQZ
Pumped Through: $��- /�/ Effluent Sewage Discharge: Yes: No:
Comments:
P U.
5S <
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Name of Person Completing Form: ��� ��L Date: 0
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Please submit completed forms to the Building Inspections Division via mail, fax or email.