3296 Sibley Memorial Hwy - Septic Maintenance Form 2024-11-07EAGAN
Imo„ �r
3830 PILOT KNOB ROAD I EAGAN, MN 55122-1810
(651) 675-5675 1 FAX: (651) 675-5694
Plan Submittal: eplansp_citvofeagan.com
Date Pumped
Site Address:
Owner's Name:
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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
Owner's Address (if different from site):
Owner's Email:
Maintainer's Name:
Private Residence:
Condition of Baffles:
Pumped Through
Comments:
# of Tanks Pumped: Putmpedallons
Owner's Phone #:
�f�, f♦ �_ � License Number: (J
Commercial: Disposal Location: f i lr Q,a A"A�{"
Type of Tanks: Size of Tanks:
Y�► (�1 �_ Effluent Sewage Discharge: Yes: No:
Name of Person Completing Form:
Date: 1 I U lu 7,+
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Please submit completed forms to the Building Inspections Division via mail, fax or email.