874 Lakewood Hills Rd - Septic Maintenance Form 2016-06-14 2010-03-27 00:24 » 6516755694 P 1/3
For Office Use 1
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Date Received: 1 1 1 l lQ
City of Eap I Staff:
3830 Pilot Knob Road ----
Eagan MN 55122
Phone: (651)675.5675
Fax: (651)675-5694
Email: commdeveloament0eltvnfeanan com
SEPTIC SYSTEM MAINTENANCE FORM
Date Pumped; '1 I #of Tanks Pumped: Total Gallons Pumped: /0 0(�
Site Address: L�A1CG Vie" 10J741
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Owner's Name:
Owner's Address(if different from site);
Maintainer's Name: P'�r ids".��� eune,4, License Number: L
Private Residence: ✓Commercial: Disposal Location: 2 Q- c -
-Condition of Baffles: )� Type of Tanks:
--�-./Y�. ._ YP — Size of Tanks: IUUV
Pumped Through: Effluent Sewage Discharge: Yes: No:
Comments:
Please submit completed forms to the Building Inspections Division via mail, fox or email.