578 Michigan Ct - Septic Maintenance Form 2025-11-13EAGAN•��• .i
3830 PILOT KNOB ROAD I EAGAN, MN 55122-1810
(651) 675-5675 1 FAX: (651) 675-5694
Plan Submittal: eglans(cDcityofeagan.com
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For Office Use
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Date Received:
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I Staff: I
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SEPTIC SYSTEM MAINTENANCE FORM
Date Pumped: _ , �:. 2 �� # of Tanks Pumped:
Total Gallons ^�
Pumped: k IA ou
Site Address: � CA
1 o('k
V
J�
Owner's Name:1
Owner's Address (if different from site):
Owner's Email:
Owner's Phone #:
Maintainer's Name: �--Gk VR,1R
&CC (^ License Number:
-Zug
e-
Private Residence: Commercial:
Disposal Location: GI- Mc ato V(.tckeix
-e._
Condition of Baffles:
Type of Tanks: I C, Size
of Tanks:
►+
LA
Pumped Through: Li
Effluent Sewage Discharge: Yes:
No:
Comments:
l
Name of Person Completing Form:
in n
1 A A IfX1 I� Date:
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Please submit completed forms to the Building Inspections Division via mail, fax or email.