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PRIVATE SEWAGE SYSTEM MAINTENANCE FORM <br /> To the system owner: It is important for you to verify the legal description,including the parcel number,with your tax <br /> records. Please indicate any changes or corrections on this form. <br /> Owner(s): ROSS BROWN Office References <br /> POWTS#: 16498 <br /> Mailing Address: 5138 TOWER LINE RD DB ID: 15978 <br /> MARSHALL WI 53559 <br /> Legal Description: NW '/ of SE '/ of Section 26,Town of Medina <br /> Subdivision: Lot: Parcel No: 0812-264-8500-0 <br /> Property Address: 5138 Towerline Rd (old House)y� l r��� q- - c Owner's Comments: 1 �� gas° S D Ky4,14kk cito‘k).04.LA,C_ <br /> Please note: The person that performs the work for you must be properly licensed and must provide the <br /> information to complete all of the statements in the certification section. Any report that does not include all of <br /> that information can not be accepted. . <br /> PRIVATE SEWAGE MAINTENANCE CERTIFICATION <br /> I have performed the following services at the above premises on Ci - 2 1-F-- 09 and certify that the <br /> results are being fully and accurately reported. (Date) <br /> 1) The liquid level in the septic tank was,orrect ❑ above outlet ❑ below outlet. <br /> 2) The septic tank)(pump chamber as pumped. <br /> 3) Th septic tank)(dump chamber was ins•ected. <br /> a) T e accumu a e 1 S occup t ess than greater than)one-third of the liquid capacity of the septic tank. <br /> b) The outlet baffle is Asolid ❑ deteriorating ❑ missing. <br /> c) There(are) are not • ack(s)(?1/4 inch wide)in the septic tank Aril floor mover. <br /> 4) Liquid discharge from the system(was) was no ) •bserved on the ground surface above or immediately adjacent to the <br /> soil absorption unit. <br /> Comments: : an ta■ (I , 1t. / ' U I I• ■ . . . ` IAA . J.A. <br /> . i ' pt1 - • <br /> Licensed Professional: 'i�r ,y, <br /> i <br /> 3 <br /> _____ 2_.__Gnjree_jA <br /> Printed Name /�!•afore License# <br /> Business Name: 11041/4 P C .C.. <br /> Return this form along with the required$26.00 fee to PUBLIC HEALTH MADISON&DANE COUNTY, 1202 NORTHPORT <br /> DRIVE,ROOM 154,MADISON,WI, 53704-2088, by 7/28/2008. Make your check payable to CITY OF MADISON <br /> TREASURER. Our phone number is(608)242-6515 if you have questions. <br /> . This form was created by PUBLIC HEALTH MADISON& DANE COUNTY for the sole purpose of achieving <br /> compliance with the requirements of Dane County Code ch 46. Any other use of this form is unauthorized and <br /> invalid. <br />