3296 Sibley Memorial Hwy - Septic Maintenance Form 2025-01-09• • 1 I IEAGAN
3830 PILOT KNOB ROAD I EAGAN, MN 55122-1810
(651) 675-5675 1 FAX (651) 675-5694
Plan Submittal: eplans(&cityofeagan.com
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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
Date Pumped: l / ' # of Tanks Pumped: Total Gallons
{ 2� 1 Pumped: l 2
Site Address: Jf �p �J; ��L+ t fh"y,,ri,j Id,) u I Ce Gtia,
Owner's Name: fly
Owner's Address (if different from site):
Owner's Email: Owner's Phone #:
1
Maintainer's Name:
� (�I�.ei � License Number:
Private Residence: X Commercial: Disposal Location: 41z. �Q t [D
Condition of Baffles: t'oC� Type of Tanks: Size of Tanks: qSO
Pumped Through: 6Ur\ WA. Effluent Sewage Discharge: Yes: No: _X
Comments:
Name of Person Completing Form: "t Date:
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Please submit completed forms to the Building Inspections Division via mail, fax or email.