540 Lone Oak Rd - Septic Maintenance Form 2025-07-14----- ---------------i
For Office Use
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Date Received: I
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3830 PILOT KNOB ROAD I EAGAN, MN 55122-1810
(651) 675-5675 1 buildinginspections(&eagammngov
SEPTIC SYSTEM MAINTENANCE FORM
Date Pumped: " �c�jA # of Tanks Pumped: Total Gallons
Pumped:
Site Address: � � �� �a � Q
Owner's Name:
Owner's Address (if different from site):
Owner's Email: J V�r C-
Maintainer's Name:
Private Residence
Condition of Baffles:
Pumped Through:
Comments:
Owner's Phone
ASST //8 License Number:
Commercial: Disposal Location: .f�• tA,114
Type of Tanks: (� d , ' Size of Tanks:
c P.
Effluent Sewage Discharge: Yes: No:
Name of Person Completing Form:
Date: 17
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Please submit completed forms to the Building Inspections Division via mail or email.