4135 South Robert Tr - Septic Maintenance Form 2025-09-29\ \ I I I
� I IEAGAN
3830 PILOT KNOB ROAD I EAGAN, MN 55122-1810
(651) 675-5675 1 FAX: (651) 675-5694
Plan Submittal: eplansP-cityofeagan.com
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For Office Use
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Date Received:
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I Staff: I
SEPTIC SYSTEM MAINTENANCE FORM
Date Pumped: CR "ISA -_ ZC-5 # of Tanks Pumped:
Site Address: 1Y --b �
Owner's Name:
Owner's Address (if different from site):
Owner's Email:
7r\ ;E
Total Gallons
Pumped:
Owner's Phone #: 4�
Maintainer's Name: t&c)c � � ��((j � 'k C— License Number:
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Private Residence: Commercial: Disposal Location:iY�
Condition of Baffles: \V -k Type of Tanks: W. Size of Tanks:
Pumped Through: 6ke-
Comments:
Effluent Sewage Discharge: Yes: No: V
Name of Person Completing Form: ---0,411 A,1Date:
/tom Yn
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Please submit completed forms to the Building Inspections Division via mail, fax or email.