3265 Lexington Ave - Septic Maintenance Form 2021-10-13 ---------------------
For Orae,Use
EAGAN
• • �• I Dara Recalled: 1
I Suit: I
`1 -------I
3830 PILOT KNOB ROAD I EAGAN.MN ii t it i b'd
(651)6755675 I FAX (651)675-5694
Plan Submittal epla,1SaC4yoteBda0:om
SEPTIC SYSTEM MAINTENANCE FORM
De1e Pumped /0 �l� ,a0[�� it ot Tanks Pumplecl. —n- Total
Soo AOtraes:
Owners Name:
Owners Address 1(Afferent from aft): `C'.�•,,`
Owner's Emil. ('1 Owners Phones (0-�i17- 9y y_5o O
Malnuners Name. �.d�(.�`�L! L7.+�w�.-C.Q� YLicense Number 7 J
47
Pnvate Residence: Commercial: Disposal Location: Ml.G —Poq UL.
Condlbon of Baffles. CT-DC,1-b TvPe of Tarso: t L4049 , SMa of Tanks:
Pumped Through: Effluent Sewage Dscharoe: Yas:
Comments.
Name of Person Completno Form. �`�`" ' T A""`� Date.
Yeo may subscribe to receive an electronic notification from the City of proposed ordinances by signing up for an email update
on the City's webe@e at tytayy,pl(yp(fayHlL4sIf11iS4Q4Li1b.0
Please submit Completed forms to the Building Inspections Division via mall,fax or emaii.