4085 Lexington Ave - Septic Maintenance Form 2016-06-10 ----------------------
For Office use I
I
Date Received;
City of Ea afl I Stafo:
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3830 Pilot Knob Road
Eagan MN 65122
Phone:(651)676-6675
Fax: (651)675-5694
Email: commdevelopmenifi)-cityofeagan.com
SEPTIC SYSTEM MAINTENANCE FORM
Date Pumped. C6 #of Tanks Pumped: Total Gallons Pumped-
Site Address: 9�' Z_ __7
el f1Z
Owners Name.-
4C- :F- 144�te_
Owners Address(if different from site)-
Maintainer:s Name: License Numt)er;
"Z_�_.
Private Residence- Commercial- Disposal Location:
Condition of Baffles: Type of Tank-s.- Size of'Tanks: Z_50-117>
Pumped Through: ,-7 Effluent Sewage Discharge: Yes- No,
Comments-
J;(/
Please submit completed forms to the Building Inspections Division via mail,fax or email.