912 Lakewood Hills Rd - Septic Maintenance Form 2012-08-07AUG-7-2012 03:34P FROM: + + + + + + + + ++
IP City of Eagan
3830 Pilot Knob Road
Eagan MN 55122
Phone: (651) 675 -5675
Fax: (651) 675 -5694
Email: commdevelopment (a?citvofeagan.com
Date Pumped:
Site Address:
Owner's Name:
Maintainer's Name:
Private Residence:
Condition of Baffles:
Pumped Through:
Comments:
Owner's Address (if different from site):
0 0- ilec A141';
Commercial:
NIL 0,40
C ) TO:6755694 P.1
SEPTIC SYSTEM MAINTENANCE FORM
41 1- # of Tanks Pum
aDD 4L.t4 I A 912 Lakewood Hills Road
geck - 611cKexs� Eagan, MN 66123.1912
Disposal Location:
Type of Tanks:
u
For Office Use
Date Received: B/6/1 2._
Staff:
Total Gallons Pumped: &t9-0
b dtia
Effluent Sewage Discharge: Yes:
Size of Tanks:
License Number: Zish
Please submit completed forms to the Building Inspections Division via mail, fax or email.
0
No: