4085 Lexington Ave - Septic Maintenance Form 2015-05-15 r �
For--- Use
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'> I Date Received; l
City of Eajan I stat .
3830 Pilot Knob Road
Eagan WIN 55122
Phone:(651) 67645675
Fax:(651)676-5694
Email:cornrndevelopment _d1yofeaclari.carn
SEPTIC SYSTEM MAINTENANCE FORM
Date Pumped: �, .�.. #ofTanks Pumped_ _ Total Gallons Pumped;
Site Address: ..
t er's Narna: �i 1 P ' Z112j,, [
Owner's Address(if different from site)-.
Maintainer's Name. .r °, l=icense Number.
Private Residence- _ Commercial: Disposal Location:
Condition 015afnes: Type of Tanks: __ Size of Tanks: /z f!C2
Pumped Through: � r Effluent Sewage D'rs barge. Yes: ---_ No:
Comments:
Please submit completed forms to the Building Inspections Division via mail,fax or email-