4085 Lexington Ave - Septic Maintenance Form 2012-05-31Jun 07 12 03:09p John & Maggie
10 City of Eaall
3830 Pilot Knob Road
Eagan MN 55122
Phone: (651) 675 -5675
Fax: (651) 675 -5694
Email: commdeveloprnent acitvofeagan.com
SEPTIC SYSTEM MAINTENANCE FORM
Date Pumped: JC" /3 [ / 1 L # of Tanks Pumped: 1 Total Gallons Pumped: 12_ SO
Site Address: ° yS L u-- .4. - f.,.- y - a ,- A 41 L S Fr,, ,•-■ / N 5 57
Owner's Name: 30 I 5e_ 1-, o e, �e r e -,...„” , fil it
r
Owner's Address (if different from site):
651 688 -6998 p.1
For Office Use
Date Received:
Staff:
�
Maintainer's Name: S License Number. L 9 ti 6
Private Residence: Commercial: Disposal Location' e of l� hi' L, /
Condition of Baffles: .0K, Type of Tanks: Se Size of Tanks: J 2._ '3
Pumped Through: /11 .t,r\ in Lie---
Effluent Sewage Discharge: Yes: No:
Comments:
Please submit completed forms to the Building Inspections Division via mail, fax or email.