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PRIVATE SEWAGE SYSTEM MAINTENANCE FORM <br /> HOPE ROD &GUN CLUB INC <br /> PO BOX 6471 <br /> MONONA, WI 53716 <br /> Office Reference <br /> System due for service on: October 01 2014 POWTS#: SAN-6589 <br /> Parcel No: 0710-354-9810-0 Subdivision: Lot: <br /> Property Address: 3435 SIGGELKOW RD TOWN OF BLOOMING GROVE <br /> Application/Project Name: <br /> Please note: The person that performs the work for you must be properly licensed and must <br /> provide the information to complete all the statements in the certification section. Any report that <br /> does not include 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 <br /> Location: <br /> Problems with tank(s)? Yes No <br /> If yes,please check all the issues observed. tank cracking or deterioratting <br /> Report additional problems and corrections baffles need repair/replacement <br /> in the comment area: <br /> liquid level above or below inlet baffle <br /> Does the system have a steel tank? Yes No <br /> Was the liquid discharge from the Yes No <br /> system observed? <br /> Comments: <br /> Licensed <br /> Professional: Printed Name Signature License# <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 @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 />