DCPZP-2016-00012 - Laserfiche WebLink

Home Browse Search

PRIVATE SEWAGE SYSTEM MAINTENANCE FORM To the system owner: It is important for you to verify the legal description, including the parcel number, with your tax records. Please indicate any changes or corrections on this form. Owner(s): MICHAEL G LEEDER POWTS#:SAN-8863 Mailing Address: 1912 COUNTY HIGHWAY BB DEERFIELD,WI 53531 Legal Description: SE%of SE%of Section 11,TOWN OF COTTAGE GROVE Subdivision: (no subdivision listed) Lot: Parcel No:0711-114-9710-9 Property Address: 1912 COTTAGE GROVE RD Comments: Please note: The person that performs the work for you must be properly licensed and must provide the information to complete all of the statements in the certification section. Any report that does not include all of that information cannot be accepted. PRIVATE SEWAGE MAINTENANCE CERTIFICATION I have performed the following services at the above premises on and certify that the results are being fully and accurately reported. (Date) 1) The liquid level in the septic tank was ❑correct ❑above outlet ❑below outlet. 2) The septic tank was ❑pumped ❑not pumped. 3) The pump chamber was ❑pumped ❑not pumped. 4) The❑septic tank ❑pump chamber was inspected(mark all that apply). a) The accumulated solids occupy Oless than ❑greater than one-third of the liquid capacity of the septic tank. b) The outlet baffle is ❑solid ❑deteriorating ❑missing. c) There Clare Clare not crack(s)(>% inch wide)in the septic tank ❑wall ❑floor ❑cover. -OR- ❑Cracks could not be observed because the tank was not pumped. 5) Liquid discharge from the system ❑was Owas not observed on the ground surface above or immediately adjacent to the soil absorption unit. Comments: Licensed Professional: Printed Name Signature License# Business Name: Return this form to Public Health Madison&Dane County,2701 International Ln Rm 204, Madison WI 53704, no later than September 2,2011. This form was created by Public Health Madison&Dane County for the sole purpose of achieving compliance with the requirements of Dane County Code ch 46. Any other use of this form is unauthorized and invalid.