810 ONeill Dr - Septic Maintenance Form 2025-07-09EAGAN
3830 PILOT KNOB ROAD I EAGAN, MN 55122-1810
(651) 675-56751 FAX: (651) 675-5694
Plan Submittal: egians@cibLqfeagan.com
Date Pumped: # of Tanks Pumped:
Site Aaaress: 12> I C) 0 )r% e. , \1 O)r
6
Owner's Name: � N vkk A gL e. -r 'a
*I-
Ownae.s Address Pf diffierpmt frnm qitp-).-
Owner's Email:
---------------------
For Office Use I
I
Date Received:
I Staff: I
I— — — — — — — — — — — — — — — — — — — — I
Total Gallons
Pumped: 1j(9(9
Owner's Phone M
Maintainer's Name: Ckr � ) 14 )&Z, -" I License Number:
7
Private Residence: Commercial: Disposal Location: -0--cei'k
Condition of Baffles: t/3t2e2j Type of Tanks: Size of Tanks:
Pumped Through: A&,jjLj It
-Corr . r-r-teate:
Effluent Sewage Discharge: Yes: No:
Name of Person Completing Form: em t il Date:
L.41 WIS !rA4
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Please submit completed forms to the Building Inspections Division via mail, fax or email.