4832 Dodd Rd - Septic Maintenance Form 2015-07-23 Aug lO 15 11 : 42a Greg Gudbjartsson 952-469-3963 p. 2
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For Office Use l
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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.