2750 Lexington Ave - Septic Maintenance Form 2012-07-05City otEaoan
3830 Pilot Knob Road
Eagan M N 55122
Phone: (651) 675 -5675
Fax: (651) 675 -5694
Email: commdeve lopment(ccityofeactan.corn
SEPTIC SYSTEM MAINTENANCE FORM
Date Pumped: " 7 — r # of Tanks Pumped: Total Gallons Pumped: 0
Site Address: 'A Lex 1Yv--011
Owner's Name:
Owner's Address (if different from site):
Maintainer's Name:
Private Residence:
Condition of Baffles:
Pumped Through:
Comments:
(-6 h'l� ,r Cau.+rI-e,t'..
S11Ior\ uil
Commercial:
7fV i L&k e�
For office Use
Date Received:
Staff:
License Number
x01 K`1
Pang 1 ( e71 -D
Type of Tanks: �` lc + n Size o` Tanks: apt
✓ Disposal Location:
vnl ri
Effluent Sewage Discharge: Yes:
Please submit completed forms to the Building Inspections Division via mail, fax or email.
No: L'""`