526 Lone Oak Rd - Septic Maintenance Form 2024-12-06�v � I I I s
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EAGAN
3830 PILOT KNOB ROAD I EAGAN, MN 55122-1810
(651) 675-5675 1 FAX:(651) 675-5694
Plan Submittal: eolans(a),citvofeacan.com
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For Office Use
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Date Received:
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I Staff:
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SEPTIC SYSTEM MAINTENANCE FORM
Date Pumped: 1 L. - V - l 1 # of Tanks Pumped:
Site Address: 5 l 1p I- o M Q. b 2. K � A
Owner's Name: V,,\ t \\ I Q R inb D t t
Owners Address (if different from site):
Owner's Email:
L
Total Gallons l 5 p O
Pumped:
Owner's Phone #: �p 5 I- 5 {. - 9 it 6
Maintainer's Name: (`^ Qy Er S t,4e.-c Jev V ; C 2 License Number: 1,.0i g
Private Residence: ✓ Commercial: Disposal Location: '4q Y P - Co t 01
Condition of Baffles: t) r.1t Y� o W r Type of Tanks: t P. S S 0 0 8 Size of Tanks: 19 0 jibo
Pumped Through: 5t'Ilnc;o;o2 Effluent Sewage Discharge: Yes: No: ✓
Comments:
Name of Person Completing Form: Date:
L'u' L`r
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