4135 South Robert Tr - Septic Maintenance Form 2025-03-10• • I EAGAN
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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: M
-0 # of Tanks Pumped
Site Address: �ia+ �.n
Owner's Name: V
Owner's Address (if different from site):
Total Gallons
Pumped: �fl0
Owner's Email: Owner's Phone #:
Maintainer's Name: L� C�Q. License Number: !-2 6
Private Residence: Commercial: _ _ Disposal Location: �ytip�YY, �C.j T e,•
Condition of Baffles: Type of Tanks: n o gk h Size of Tanks: Sb0
Pumped Through: ryNOL4N W Effluent Sewage Discharge: Yes: No:
Comments:
-�MlName of Person Completing Form: 941A OP Date: 3I0( ` JI
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Please submit completed forms to the Building Inspections Division via mail, fax or email.