578 Michigan Ct - Septic Maintenance Form 2025-01-08---------------------
For Office Use
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Date Received:
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3830 PILOT KNOB ROAD I EAGAN, MN 55122-1810
(651) 675-5675 1 FAX: (651) 675-5694
Plan Submittal: eplans(ZDcityofeagan.com
SEPTIC SYSTEM MAINTENANCE FORM
Date Pumped: Q# of Tanks Pumped: Total Gallons
P V1.2,,, .Z� Pumped: flO
Site Address: J -7 grn- u
Owner's Name:
Owner's Address (if different from site):
Owner's Email:
Owner's Phone #:
Maintainer's Name: LA-evcih Z` S l License Number: 1� I
Private Residence: X Commercial: Disposal Location: L"o c, �-�,1 d G
Condition of Baffles: Type of Tanks: G llq(N Size of Tanks: i DQ 0 1 -5o O
Pumped Through: 11 Pt De -
Comments:
Name of Person Completing Form:
Effluent Sewage Discharge: Yes: No: X
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Please submit completed forms to the Building Inspections Division via mail, fax or email.