3265 Lexington Ave - Sptic Maintenance 10/2/240
EAGAN
3830 PILOT KNOB ROAD I EAGAN, MN 55122-1810
(651) 675-5675 FAX: (651) 675-5694
Plan Submittal: eplansOcitvofeaaan.com
SEPTIC SYSTEM
Date Pumped: 10 A # of Tanks Pumped:
Site Address: 3 45 `�" A 1 "'' ` "
Owner's Name:
Owner's Address (if different from site):
Owner's Email: vl ew 01
Maintainer's Name:
Private Residence:
Condition of Baffles:
e" e-1- SO-, - M J� ( {
Commercial: Disposal Location:
GG W A Type of Tanks:
Pumped Through: 1 "R��1e-5 Effluent
Comments:
V
Name of Person Completing Form:
You may subscribe to receive an electronic notification from the City of
on the City's website at www.citvofeanan.com/subscribe.
--------------------�
For Office Use
I I
Date Received:
I I
I I
1 Staff:
-------------------�
FORM
Total Gallons
Pumped:
Owner's Phone #: M q\ , 1 / 0' 78 yam^
License Number: 9 I
1
j'� ��.rc�,Pc� 1
/^ n cx- Q— l
M rN r-fSize of Tanks: _1 0o
age Discharge: Yes: No: _ V
Date: 10 A ^07 /
ordinances by signing up for an email update
Please submit completed forms to the Building Inspectiol s Division via mail, fax or email.