4135 Dodd Rd - Septic Maintenance Form 2021-12-27License Number°
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Commercial: Disposal Location: E r'Y1 f],fec - � a �• e �.� ,� Tai.{mtn ,7 y
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lajcriO N Size of Tanks: 1A e d 94-if
Effluent Sewage Discharge: Yes: ° No• y
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Type of Tanks:
City of Eaall
3830 Pilot Knob Road
Eagan M N 55122
Phone: (651) 675-5675
Fax: (651) 675-5694
Email: cornmdevelopment@cityofeadan.com
For Office Use
Date Received:
Staff:
SEPTIC SYSTEM MAINTENANCE FORM
Date Pumped: 12 -"a 7-7/ # of Tanks Pumped: � Total Gallons Pumped: 1/00
Site Address: _ Y13 5 O W Rei S S 1 Z.3. .
Owner's Name: oPrid6t./e u p I [� t/i'if'f
Owner's Address (if different from site):
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Maintainer's Name: .P
Private Residence:
Condition of Baffles:
Pumped Through:
Comments: yvi
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Please submit completed forms to the Building Inspections Division via mail, fax or email.