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�Y� <br /> `� �`Public Health <br /> MADISON&DANE COUNTY <br /> Healthy people.Healthy places. <br /> PRIVATE SEWAGE SYSTEM MAINTENANCE FORM <br /> Owner Name DEERFIELD ROD &GUN CLUB INC <br /> Mailing Address PO BOX 47 <br /> City DEERFIELD State WI Zip Code 53531 <br /> Office Reference <br /> POWTS#: SAN-17633 <br /> Parcel No: 0712-102-9001-0 Subdivision: Lot: <br /> Property Address: 4372 ROD&GUN CLUB RD,TOWN OF DEERFIELD <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 <br /> all of that information cannot be accepted. <br /> PRIVATE SEWAGE MAINTENANCE CERTIFICATION <br /> Date serviced: #of tanks serviced: <br /> Amount of accumulated solids: < 1/3 tank capacity > =1/3 tank capacity <br /> Gallons Pumped: Disposal Location: <br /> Problems with tank(s)? Yes —No <br /> If yes, please check all issues observed. Report _tank cracking or deteriorating <br /> additional problems and corrections in the comment baffles need repair/replacement <br /> area: <br /> liquid level above or below inlet baffle <br /> manhole cover over pump or filter <br /> is buried or unsecured <br /> Does the system have a steel tank? —Yes No <br /> Was liquid discharge from the Yes No <br /> system observed? — — <br /> Does system have a seepage pit? —Yes —No <br /> Report repairs made on-site: <br /> Comments: <br /> Printed Name Signature License# <br /> Licensed Professional: <br /> Business Name: <br /> Septic maintenance reports may be returned to the Department by the following means: <br /> • Online Submittal by your septic pumper/maintenance provider <br /> • Email the completed and signed form to privatewellseptic(cr�publichealthmdc.com <br /> • Fax completed and signed form to 608-242-6435 <br /> • Mail completed and signed form to: Public Health Madison and Dane County <br /> 2701 International Ln, Rm 204 <br /> Madison,WI 53704 <br />