526 Lone Oak Rd - Septic Mantenance Form 2024-08-30n • � r r
EAGAN
3830 PILOT KNOB ROAD I EAGAN, MN 55122-1810
(651) 675-5675 1 FAX: (651) 675-5694
Plan Submittal: eolans(a)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: _ O , # of Tanks Pumped: 1 Total Gallons
1 Pumped:
tine AadreSS:
Owners Name:
Owners Address (if different from Site)
Owner's Email:
Owner's Phone #: 651.3 o $ —110c)
Maintainer's Name: 1A2 tr't J P,rVie2 License Number:
Private Residence: ✓ Commercial: Disposal Location: L1„A h?DIl,kI
Condition of Baffles: u Y\%✓1 o W n Type of Tanks: C P SS�T Size of Tanks: 10 n O
Pumped Through: cj k,&rw\ O: P e
Commence:
Effluent Sewage Discharge: Yes: No: V/
Name of Person Completing Form: e.Ylr IS 'aQnpY' Date: p - J O - ZT
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Please submit completed forms to the Building Inspections Division via mail, fax or email.