4775 Dodd Rd - Septic Maintenance Form 2017-05-20 RECEIVED ------ -------------I
For Office Use
JUN 0 5 2016 Date Received:
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400 City of Ea pall I Staff
I— — —-
3830 Pilot Knob Road ———--- ——
Eagan MN 55122
Phone: (651) 675-5675
Fax: (651)675-6694
Email: commdevel
SEPTIC SYSTEM MAINTENANCE FORM
Date Pumped: -7
4 of Tanks Pumped: Total Gallons Pumped: 000
Site Address: 7 7 S 00A
Owner's Name, (.)U—
Owner's Address(if different from site):
Maintainer's Name � �-JY
License Number:
Private Residence: Commercial: s^ Disposal Location: —:R ILA-g— LAew
Condition of Baffles: C Type of Tanks: Size of Tanks: Z -2(jo
Pumped Through: L Effluent Sewage Discharge: Yes, No:
Comments:
Please submit completed fog ms to the Building Inspections Division via mail, fax or email.