820 ONeill Dr - Septic Maintenance Form 2025-07-09% %
t 0
014
EAGAN
3830 PILOT KNOB ROAD I EAGAN, MN 55122-1810
(651) 675-5675 1 FAX: (651) 675-5694
Plan Submittal: epIans(@,ci!yofeagan.com
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For Office Use
Date Received:
I Staff,
I— — — — — — — — — — — — — — — — — — — I
SEPTIC SYSTEM MAINTENANCE FORM
Date Pumped: -1 - � - 1.5 # of Tanks Pumped:
SIte AcldrOSS: b L () 0
r1wnar'Q K]Amw M " y% P "VP—V-V-
Owner's Address (if different from site.):
Total Gallons
Pumped:
1500
Owner's Email: Owner's Phone #:
Maintainer's Name: ur e-Y, I C e, License Number: Ll I
Private Residence: V/ Commercial: Disposal'Locati6n:
Condition of Baffles: 0V%Ky-%bWn Type of Tanks: �et Vc- toWele- Size of Tanks: 11600
Pumped Through: to f!i Effluent Sewage Discharge: Yes: No: —
Comm., vertte:
Name of Person Completing Form: L, r r%A, #'.h A%^ a Date: C-1.
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Please submit completed forms to the Building Inspections Division via mail, fax or email.