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4832 Dodd Rd - Septic Maintenance Form 2015-07-23 Aug lO 15 11 : 42a Greg Gudbjartsson 952-469-3963 p. 2 ----------------------- For Office Use l I i I Date Received: Ok l Cit of Ea an y I Staff----------------- i 3830 Pilot Knob Road Eagan MN 55122 Phone: (651) 675-5675 Fax: (651) 675-5694 Email: commdeyelooment(Mcitvofeacan.com SEPTIC SYSTEM MAINTENANCE FORM Date Pumped: '- —1!5 #of Tanks Pumped: L Total Gallons Pumped: Site Address: -- Owner's Name: M e-. s'Z Owner's Address(i(different from site): MaEMalner's Name: , License Number: Z Private Residence; _ Commercial: _ Disposal Location: Condition of Baffles: 62�L Type of Tanks: Size of Tanks: � 7 Pumped Through: _ A _ Effluent Sewage Discharge: Yes: No: Comments: Please submit completed forms to the Building Inspections Division via mail,fax or email.