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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, <br /> with your tax records. Please indicate any changes or corrections on this form. <br /> Owner(s): CRAIG A HALTOM POWTS#: SAN-19491 <br /> Mailing Address: 4799 MISSOURI RD <br /> MARSHALL, WI 53559 <br /> Legal Description: SW 1/4 of SE 1/4 of Section 34, TOWN OF MEDINA <br /> Subdivision: (no subdivision listed) Lot:4 Parcel No: 0812-344-9095-0 <br /> Property Address:4799 MISSOURI RD <br /> Comments: <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 <br /> include all of that information cannot be accepted. <br /> PRIVATE SEWAGE MAINTENANCE CERTIFICATION <br /> I have performed the following services at the above premises on <br /> and certify that the results are being fully and accurately reported. (Date) <br /> 1) The liquid level in the septic tank was Dcorrect Dabove outlet Dbe low outlet. <br /> 2) The septic tank was ❑pumped Dnot pumped. <br /> 3) The pump chamber was Dpumped Dnot pumped. <br /> 4) The Oseptic tank ❑pump chamber was inspected (mark all that apply). <br /> a) The accumulated solids occupy ❑less than Dgreater than one-third of the liquid capacity of the <br /> septic tank. <br /> b) The outlet baffle is ❑solid Ddeteriorating Dmissing. <br /> c) There Dare Dare not crack(s) (> ' inch wide)in the septic tank Dwa II ❑floor Dcover. <br /> -OR- ❑ Cracks could not be observed because the tank was not pumped. <br /> 5) Liquid discharge from the system ❑was Dwas not observed on the ground surface above or immediately <br /> adjacent to the soil absorption unit. <br /> Comments: <br /> Licensed Professional: <br /> Printed Name Signature License# <br /> Business Name: <br /> Original Due Date Return this form to Public Health Madison & Dane County, 2701 <br /> November 23 2013 International Ln Rm 204, Madison WI 53704, no later than March 05 <br /> 2014 <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 <br /> unauthorized and invalid. <br />