861 Lakewood Hills Rd - Septic Maintenance Form 2025-06-09• • i I I
3830 PILOT KNOB ROAD I EAGAN, MN 55122-1810
(651) 675-5675 1 FAX: (651) 675-5694
Plan Submittal: eplansAcityofeagan.com
---------------------
For Office Use
I I
Date Received:
I
I I
I Staff:
I
SEPTIC SYSTEM MAINTENANCE FORM
Total Ga
Date Pumped: t��b�5 # of Tanks Pumped: 1 Pumpedllons
Site Address: �W\ k (1\K i, W UA ` k\\5_ I U Cti
Owner's Name:
Owner's Address (if different from site):
Owner's Email:
Maintainer's Name:
Owner's Phone #:
VSoo
License Number: l � � 0)
Private Residence: ly Commercial: Disposal Location:V-i(AcAlfilA.
V
Condition of Baffles: C"jko� Type of Tanks: Size of Tanks:
Pumped Through: Nwx\w U\� Effluent Sewage Discharge: Yes: No: J�
Comments:
Name of Person Completing Form:
You may subscribe to receive an electronic
on the City's website at www.cityofeagan.co
Date: V- d l Zs�-
from the City of proposed ordinances by signing up for an email update
Please submit completed forms to the Building Inspections Division via mail, fax or email.
3830 PILOT KNOB ROAD I EAGAN, MN 55122-1810
(651) 675-5675 1 FAX: (651) 675-5694
Plan Submittal: eplansAcityofeagan.com
---------------------
For Office Use
I I
Date Received:
I
I I
I Staff:
I
SEPTIC SYSTEM MAINTENANCE FORM
Total Ga
Date Pumped: t��b�5 # of Tanks Pumped: 1 Pumpedllons
Site Address: �W\ k (1\K i, W UA ` k\\5_ I U Cti
Owner's Name:
Owner's Address (if different from site):
Owner's Email:
Maintainer's Name:
Owner's Phone #:
VSoo
License Number: l � � 0)
Private Residence: ly Commercial: Disposal Location:V-i(AcAlfilA.
V
Condition of Baffles: C"jko� Type of Tanks: Size of Tanks:
Pumped Through: Nwx\w U\� Effluent Sewage Discharge: Yes: No: J�
Comments:
Name of Person Completing Form:
You may subscribe to receive an electronic
on the City's website at www.cityofeagan.co
Date: V- d l Zs�-
from the City of proposed ordinances by signing up for an email update
Please submit completed forms to the Building Inspections Division via mail, fax or email.