3325 Lexington Ave - Septic Maintenance Form 2016-04-08 I --------------------
E Clt of � Date Received:
I I
I Staff I
3830 Pilot Knob Road i -----
Eagan MN 55122 -------- ---------I
Phone: (651)675-5675
Fax:(651)675-5694
Email: commdevelo ment(aklr�.,se _
om
SEPTIC SYSTEM MAINTENANCE FORM
Date Pumped:
__ #of Tanks Pumped
Total Gallons Pumped: _ /(JUO
Site Address: 33 oZ.S �C k r to(q ,��
Owner's Name V S
Owner's Address(if different from site):
Maintainer's Name �p i
License Number: _1 LO(oS-
Prrvaie Residence: �`
Commercial: Disposal Location:
Condition of Baffles:
Type of Tanks: �N(-XP f, Size of Tanks:
U
Comments:
Pumped Through: —_ K.►�to�,t e T�--
Effluent Sewage Discharge. Yes
- No:
Please submit completed forms to the Building Inspections Division via mail,fax or email.