4015 Dodd Rd - Septic Maintenance Form 2017-06-12City of Eagan
3830 Pilot Knob Road
Eagan MN 55122
Phone: (651) 675-5675
Fax: (651) 675-5694
Email: commdevelopment(o�cityofeagan.com
Date Pumped:
Site Address:
Owner's Name:
RECEIVED
JUN 1 3 2016
For Office Use
Date Received: la 13 / 17
Staff:
SEPTIC SYSTEM MAINTENANCE FORM
(3(..c.- 12 -
# of Tanks Pumped: Total Gallons Pumped:
L ®\S` cocMct
i\AyY ()ct"s o v
Owner's Address (if different from site):
Maintainer's Name: f,Si7 T( C License Number: 9c/
Private Residence: x Commercial: Disposal Location:
Condition of Baffles: ? 74 Type of Tanks: g L Size of Tanks: 10e
Pumped Through: /2 7 (Air (?v i l( Effluent Sewage Discharge: Yes: No: (
Comments: Gc42C( Cc='11c4p -t
Please submit completed forms to the Building Inspections Division via mail, fax or email.
SCHLOMKA'S VAC TRUCK SERVICE INC. No. 2403
(651) 437-7284 • FAX: (651) 437-9405
CUSTOMER:
NOVA
DATE: ao - `'L- i '"}
JOB LOCATION: L4 -r I c
"Dacia
Q...0
E/
/jam" MN
P.O. #:
WORK
COMPLETED: U Cc)
W.O. #:
EQUIPMENT USED:
HOURS
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oect
oc - -' cA
DESCRIPTION OF WORK:
PRINT NAME & SIGN
yRa 0/1/
/1//r, Customer's Agent
GDI No. 82829 6/2011
Aug 1717, 02:12p Schlomka's Vac Truck
City of Wall
3830 Pilot Knob Road
Eagan MN 55122
Phone: (651) 675-5675
Fax: (651) 675.5694
Email: commdevelopment(a�cityofeagan.com
651-437-9405 p.2
For Office Use
Date Received: U 1 t S / �1 `
Staff:
SEPTIC SYSTEM MAINTENANCE FORM
Date Pumped: sC ' - 2_on # of Tanks Pumped: Total Gallons Pumped; 2- vw
Site Address: 40.c, JQ oci6 t a o . cy,A4 t v% A,vk
Owner's Name: 0/1 l ovk v_ .5
Owner's Address (if different from site):
Maintainer's Name: Sc L Owi(( O PVTU- G License Number: 02_
Private Residence: Commercial: Disposal Location:
�'.30 S `2/ Q Size of Tanks: V1/43013
Condition of Baffles: Type of Tanks:
Pumped Through: Y "/ 1 6 -AA - \A/CAF_ Effluent Sewage Discharge: Yes: No: X
Comments:
Please submit completed forms to the Building Inspections Division via mail, fax or email.