3981 Lexington Ave - Septic Maintenance Form 2024-12-05 -- TEMP HOLDING TANK*W • • EAGAN
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3830 PILOT KNOB ROAD I EAGAN, MN 55122-1810
(651) 675-56751 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:
3191 L -0 -
Total Gallons ¢�
Pumped: 0
Owner's Name: % 1'-1r' T 110
Owner's Address (if different from site): 50 ( LV OLCI�, a> ," P
Owner's Email: Owner's Phone #:
D (� t
Maintainer's Name:, 1� S License Number: %
Private Residence: Commercial: X Disposal Location:
Condition of Baffles: �`— Type of Tanks: O 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:_ Ud VI
Date:
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