4395 South Robert Tr - Septic Maintenance Form 2025-05-21% q
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VA A& 4P
EAGAN
3830 PILOT KNOB ROAD I EAGAN, MN 55122-1810
(651) 675-5675 1 FAX: (651) 675-5694
Plan Submittal: epIans(@cjbtgjea @cityofeaAan.com
Date Pumped: # of Tanks Pumped:
2
Site Address: �- S- -I b, R D e"r k Te -\
Owner's Name: bcAnxrAt
Owner's Address (if different from site):
Owners Email:
---------------------
For Office Use
Date Received:
I Staff:
I— — — — — — — — — — — — — — — — — — — — — I
Total Gallons
Pumped:
Owner's Phone M
M
Maintainer's Name: P.4 9-V' C-y License Number:
Private Residence: V/ Commercial: Disposal Location: Vnp-,V-.
Type of Tanks:
Condition of Baffles: � b D A e Size of Tanks: Ira 60 6 0 t)
T
,4Ln
Pumped Through: � -Mn ® \ t S
Comments.,
Effluent Sewage Discharge: Yes: No:
Name of Person Completing Form: Date:
qVN t%C
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on the City's website at MMw.cityofqagan.com1subscrIbe.
Please submit completed forms to the Building Inspections Division via mail, fax or email.