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4730 Dodd Rd - Septic Maintenance Form 2016-05-13
--------------------- For Office Use I I Date Received: City Of Ea in Staff: ------------I 3830 Pilot Knob Road Eagan MN 55122 Phone: (651) 675-5675 Fax: (651)675-5694 Email: commdevelopment Ocitvofeagan.com SEPTIC SYSTEM MAINTENANCE FORM Date Pumped: -' 13 — #of Tanks Pumped: 1 Total Gallons Pumped: l SC) Site Address: 1 �3© Owner's Name: RC t`�t1e �c �r\Cti-� Owner's Address(if different from site): 1 Maintainer's Name: � C.In.Q 5 License Number: Private Residence: Commercial: Disposal Location: m \T`q,, U-5T 1 Condition of Baffles: \h0,cA — !PkQS-kZC__ Type ooff,Tanks: �-;i e— Size of Tanks: Pumped Through: � � tQyr,� Iii }( oN Effluent Sewage Discharge: Yes: No: Comments: —tom Ak." e 1 at C� tp�Cl p k o-S4�c— �f \ 2 C 6 uv Y CS-CA,- cIY,U3 cr l� Cum C.stnn C� .o r+�c - � cz,nd Please submit completed forms to the Building Inspections Division via mail, fax or email.