Untitled ---------------------
♦ I For Office Use
♦• ♦� �� �� I Date Received:
EAGAN I I
I Staff: I
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3830 PILOT KNOB ROAD I EAGAN, MN 55122-1810
(651)675-5675 1 buildinginspections(cDeagammnaov
SEPTIC SYSTEM MAINTENANCE FORM
Date Pumped: q-1
#of Tanks Pumped: 3 Total Gallons
)Z5 Pumped:
' y
Site Address: ` 0 Dpcid go;
Owner's Name: 1" • 0u y ki
Owner's Address (if different from site):
Owner's Email: ' Vrle 6-0)/V)) Owner's Phone#: W— yd
-y3_40
Maintainer's Name: 4I1 Si t✓ W License Number:
Private Residence: Commercial: Disposal Location: Z
Condition of Baffles: _ �
Type of Tanks: �G Size of Tanks:
Pumped Through: Vh4 h��,,,,CQ h� Effluent Sewage Discharge: Yes: No: _
Comments:
en
Name of Person Completing Form: ► (' Date: `7�cT+ / 7-
You may subscribe to receive an electronic notification from the City of proposed ordinances by signing up for an email update
on the City's website at citvofeagan.com/subscribe.
Please submit completed forms to the Building Inspections Division via mail or email.
iENNES SEPTIC PUMPING, LLC john@hennesseptic.com
idividual Sewage Treatment System (ISTS) Pumping Record 952-403-0058
Iwner Address
'urnper No.of Tanks Pumped Total Gallons Pumped
;heck all that apply:❑Residential 0 Commercial ❑Rental
❑ Septic ❑ Holding ❑Pump Chamber ❑Cesspool ❑Abandoned ❑Other:
;ondition of Baffles (baffles must be inspected) ❑Acceptable ❑Unacceptable ❑Replaced Baffles
teason for pumping? Water tight tank? ❑ Yes ❑ No
Disposal Location (be specific)
ny tank leakage below or above the operating depth? ❑ Yes '❑ No
lumped From: ❑Maintenance Hole ❑Removed Tank Lid(stave,for example) ❑Inspection Pipe(see below)
have been informed about the correct tank cleaning procedures and understand that I risk having my system fail prematurely if the tank is not
umped through the Maintenance Hole/Tank Lid to enable the removal of solids.
ignature of Owner/Owner's Agent Reason for not pumping through the Maintenance Hole/Tank Lid
afety Concerns/Repairs
urnper/Inspector Signature Date
,nly one permit is needed per ISTS.If there is more than one ISTS on a property,submit a separate permit for each ISTS.Submit a;permit whenever
tank is pumped for abandonment.Pumping the tank does not constitute a compliance inspection.