4115 Lexington Way - Septic Maintenance Form 2020-10-1241�
City of EallaIl
3830 Pilot Knob Road
Eagan MN 55122
Phone: (651) 675-5675
Fax: (651) 675-5694
Email: commdevelopment(a-cityofeagan.com
Date Pumped:
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For Office Use
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I Date Received: ,
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SEPTIC SYSTEM MAINTENANCE FORM
O - 1 a - a -O # of Tanks Pumped: Total Gallons Pumped: d
Site Address: `S Le Y--% YA �-� Y� "" '� G qg n
Owner's Name: Gus S
Owner's Address (if different from site):
Maintainer's Name: L� Qacl" J� Y �Cti n Q�e- License Number:
Private Residence: X Commercial: Disposal Location: EnCQ e ` I -,a, -�:GY m, YW% &
Condition of Baffles: Type of Tanks: Size of Tanks J O CY) E'aCIA-
Pumped Through: l ei rncth�S Xa Effluent Sewage Discharge: Yes: No: ' (
Comments: ZjLt c� Yl,jL 4'Y� e ��`�-11� r�' �'� �'� Y '
Please submit completed forms to the Building Inspections Division via mail, fax or email.