HomeMy WebLinkAbout526 Lone Oak Rd - Septic Maintenance Form 2026-4-15---------------------
For Office U.
EAGAN
•. • Date ReraWed:
I I
I BWR: I
I I
3830 PILOT KNOB ROAD I EAGAN, MN 55122-1810
(651) 675-5675 1 buildincinsoecbonsaeacammnoov
SEPTIC SYSTEM MAINTENANCE FORM
Date Pumped:
- 15 -
# of Tanks Pumped:
IL
Total Gallons
Pumped:
16 5 0
Site Address:
bl-6
Uyip
OaIC Rd
Owners Name: Vy 1 11 , Q• K p p D i-t
Owners Address (if different from site):
Owners Email:
Owners Phone t, IA • -1100
Maintainer's Name: Mti tY Stw tr )t'rV*-Ct License Number. 01`5
Private Residence: Commercial: Disposal Location: St QAJ1 Toexi Mtf!(I P1ama
Condition of Baffles: UhKYlbwlh Typeof Tanks: C.CS4b 0&1 Size of Tanks: 1000T L
Pumped Through: bN&VIA9"PC- Effluent Sewage Discharge: Yes: No: _y/
Comments
Name of Person Completing Form: r^���'Dam:
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Please submit completed forms to the Building Inspections Division via mall or email.