4900 Dodd Rd - Septic Maintenance Form 2020-09-16--------------------
For Office Use
I . I
city Of I,'(1 I Date Received: I
I I
3830 Pilot Knob Road I Staff: I
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Eagan MN 55122 -------____— I
Phone: (651) 675-5675
Fax: (651) 675-5694
Email: commdevelo ment cit ofea an.com
SEPTIC SYSTEM' MAINTENANCE FORM
1lDate Pumped: � 6 i
# of Tanks Pumped:
qj /'t j Total Gallons Pumped: r G
Site Address: ` (�/ �
259 Owner's Name: °
Owner's Address (if different from site):
Maintainer's Name:
Private Residence:License Number: gq
Commercial: Disposal Location:
Condition of Baffles:
Type of Tanks: Size of-Tanks: ✓�f�
Pumped Through: `
Effluent Sewage Discharge: Y
Comments: D � es: No:
kj
Please submit completed forms to the Building InspectionsaDivision via mail, or email: