2970 Dodd Rd - Septic Maintenance Form 2016-09-24 2010-07-04 02:54 > 6516755694 P 1/3
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For Office Use
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Date Received: tp !
Cit of Eapn l 5� 1 1
3930 Pilot Knob Road
Eagan MN 55122
Phone:(01)676-5675
Fax: (651)673-5994
Email: commdevelooment9 cltyofeagan.com
SEPTIC SYSTEM MAINTENANCE FORM
Date Pumped: z r *of Tanks Pumped: Total Gallons Pumped: J 27�&
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Site Address; (/�
Owner's Name: 1-6,1)1 /c
Owner's Address(if different from site):
Maintainer's Name: ,�Ek?-r C_ �CJ/`7P License Number: L Y96
Private Residence; V Commercial- Disposal Location: _ �92 '
Condition of Baffles:
6 a4 Type of Tanks: 1pfuscAlJ* Size of Tanks: 5
Pumped Through: /✓l!}eFi Effluent Sewage Discharge: Yes: No:
Comments;
Please submit completed forms to the Building Inspections Division via mall,fax or email,