4065 Lexington Ave - Septic Maintenance Form 2012-06-07City of Eagan
3830 Pilot Knob Road
Eagan MN 55122
Phone: (651) 675 -5675
Fax: (651) 675 -5694
Email: commdevelopment (a7citvofeagan.com
Date Pumped:
Site Address:
Owner's Name:
Maintainer's Name:
Private Residence:
Condition of Baffles:
Pumped Through:
Comments:
SEPTIC SYSTEM MAINTENANCE FORM
# of Tanks Pumped:
1-0(0S Le x i n. 4v- S
r a (a ,k. SIOrr
Owner's Address (if different from site):
5 . AN\064L -4_
Commercial:
(f)
RECEIVED
JUN 082012
Type of Tanks: Lon C
Disposal Location:
L
2,
For Office Use
Date Received:
Staff: n
t
Total Gallons Pumped:
License Number: 2 9R1
1
17 0
/a®
Size of Tanks: `2&'
Effluent Sewage Discharge: Yes: No:
Please submit completed forms to the Building Inspections Division via mail, fax or email.