4135 South Robert Tr - Septic Maintenance Form 2025-01-23---------------------
For Office Use
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Date Received:
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I Staff: i
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3830 PILOT KNOB ROAD I EAGAN, MN 55122-1810
(651) 675-5675 1 FAX: (651) 675-5694
Plan Submittal: eplans(c)cityofeaaan.com
SEPTIC SYSTEM MAINTENANCE FORM
Date Pumped: I n�� j 5 # of Tanks Pumped:
Site Address: 0 ) 3
Owner's Name:
Owner's Address (if different from site):
Owner's Email:
+ f-
Total Gallons a a
Pumped:"�K t
Owner's Phone #:
Maintainer's Name: �r�License Number: ,
Private Residence: Commercial: Disposal Location: 9 f—'e t oc�c. '°
Condition of Baffles: Type of Tanks: 1 `0i(� Size of Tanks: � C)
Pumped Through: PiRe Effluent Sewage Discharge: Yes: No:
Comments:
Name of Person Completing Form: ADate:
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Please submit completed forms to the Building Inspections Division via mail, fax or email.