1035 Cliff Rd - Septic Maintenance Form 2025-06-09• • 0 i
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3830 PILOT KNOB ROAD I EAGAN, MN 55122-1810
(651) 675-5675 1 FAX: (651) 675-5694
Plan Submittal: eplanspcitvofeagan.com
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For Office Use
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Date Received:
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I Staff:
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SEPTIC SYSTEM MAINTENANCE FORM
Date Pumped: 13 I ��# of Tanks Pumped: Total Gallons
Pumped:
IN
Site Address: V)5 i \\!A UNA i�CN 0xr) a W� EF2 \ 1Z )
Owner's Name:
Owner's Address (if different from site):
Owner's Email:
Owner's Phone #:
\19M
Maintainer's Name: �(�1�,�� S �Uk� 9 ��t ice. �Cf,(ll e'l License Number: A2ur)
Private Residence: _ Commercial: Disposal Location: j(i 17 jit trVi`n,c1- VV61-gjr '(, rZ el r
Condition of Baffles: Type of Tanks: Size of Tanks:�-
Pumped Through:���' yy�, Effluent Sewage Discharge: Yes: No: X
Comments:
Name of Person Completing Form:
Date: UP 6 Zr
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Please submit completed forms to the Building Inspections Division via mail, fax or email.