4832 Dodd Rd - Septic Maintenance Form 2012-06-12Jul 06 12 10:32a
Cite of Evan
3830 Pilot Knob Road
Eagan MN 55122
Phone: (651) 675 -5675
Fax: (651) 675 -5694
Email: commdevelopment (a.cityofeagan.com
Date Pumped:
Site Address:
Owner's Name:
Owner's Address (if different from site):
Maintainer's Name:
Private Residence:
Condition of Baffles:
Pumped Through:
Comments:
Greg Gudbjartsson
(; - t Z Z-- # of Tanks Pumped:
952 - 469 -3963
SEPTIC SYSTEM MAINTENANCE FORM
I
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Commercial:
ll
For Office Use
Date Received:
Staff:
eiteP/2 ` 'E4
p.
Total Gallons Pumped: / e't
License Number: �J
Disposal Location:
Type of Tanks: Size of Tanks:
Effluent Sewage Discharge: Yes: No:
Please submit completed forms to the Building Inspections Division via mail, fax or email.