526 Lone Oak Rd - Septic Maintenance 11-7-25EAGAN
3830 PILOT KNOB ROAD I EAGAN, MN 55122-1810
(651) 675-56751 FAX: (651) 675.5694
Plan Submittal: eolansfrDcituofeaaan com
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� For OFlise Use I
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Data RecWmd:
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SEPTIC SYSTEM MAINTENANCE FORM
Date Pumped: I `_ -1 A f # of Tanks Pumped: 2 Total Pumped: Gallons J 0 O
. lm Adaress: t 16 l n"o 0 2LA R d
Owners Name: 4 ;'1 t P_, 1'T b b O {i
flwn.rc AAAm. a /if di6wrent fmm Nta1
Owners Email:
Owners Phone iF.
Maintainers Name: _ iAp_.1Br r7¢.v.LY' C�6.ry G . License r. se Number.
�l �1
Private Residence: Commensal: Disposal Locadon: _ DJi Qg.J� 1Y2al"it l p
ConditionofBa6les: UNKvt0Wy1 Typeofranks: 2.99 DIS SizeofTanks: IDOO X
Pumped Through: 9 -ay%. AT Ip P. Effluent Sewage Discharge: Yes: No: I-,
Commence:
Name of Person Completing Form: e!: n" bc' � Date: It• 1 • L6
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Please submit completed forms to the Building inspections Division via mail, fax or email.