3305 Lexington Ave - Septic Maintenance Form 2023-10-16,R4l1 rjEAGAN
3830 PILOT KNOB ROAD I EAGAN, MN 55122-1810
(651) 675-5675 FAX: (651) 675-5694
Plan Submittal: epians citvofeaoan corn
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For office Use
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Date Received: I
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! Staff: I
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SEPTIC SYSTEM MAINTENANCE FORM
Date Pumped: _ - Z # of Tanks Pumped:I — pumped lions t
Site Address: �—rit lCi f1°j �l out, 7
Owner's Name: � 1 Lc)54-tj Jo
Owner's Address (if different from site):
Owner's Email: Owner's Phone #:
Maintainer's Name: IAP - ye r 5 t* t r t.r v i c e License Number: 0115
Private Residence: Commercial: Disposal Location: Trt �+ .r, e n r V 1, .t n fi .-
Condition
Condition of Baffles: t wt.A. Type of Tanks: G Size of Tanks: 60c..ri.-,/
Pumped Through: 54Z&4,1 !X ?l0 f Effluent Sewage Discharge: Yes: No:
Comments:
Name of Person Completing Form: � Date: to -� —
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Please submit completed forms to the Building inspections Division via mail, fax or email.