3981 Lexington Ave - Septic Maintenance Form 2024-12-05• •• •
• • EAGAN
3830 PILOT KNOB ROAD EAGAN, MN 55122-1810
(651) 675-5675 1 FAX: (651) 675-5694
Plan Submittal: eplansCab_cityofeagan.com
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For Office Use
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Date Received: 1
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I Staff:
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SEPTIC SYSTEM MAINTENANCE FORM
Date Pumped: — d s�� # of Tanks Pumped:
Site Address: o iC fydl o n
Owner's Name: % 1-V- T 1-1 0
Owner's Address (if different from site): 3501
Owner's Email:
Total Gallons ¢�
Pumped: 0
Owner's Phone #:
D t
Maintainer's Name: �,,� 1� 0 S License Number: %
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Private Residence: Commercial: X Disposal Location: /iiiLKA CA.,,,, -
Condition of Baffles: Type of Tanks: 0 1 0 Size of Tanks: U 5o
Pumped Through: t t D , p e. Effluent Sewage Discharge: Yes: No: X
Comments:
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Name of Person Completing Form: Date:VI
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