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F• PRIVATE SEWAGE SYSTEM Ir St. Cd01N
uro.m Bull oulwn INSPECTION REPORT vaw+n SAN-2020-010
GENERALINFORMATION (ATTACH TO PERMIT) MiNt'll,ll
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Steve and Heather Lmes� •w TOWN OF HUOSON no 020A439-25-025
25.29.19.2751A
TANKINFORMATION ELEVATION DATA
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TANK SETBACK INFORMATION
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OWNER CERTIFICATION
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1 1 A 14) I A -r fr- n I A A I n^ t' EAST LINE
V I V L .rl I I C. L L fl 1 V L v '-__QUARTER
ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEN.NENT
FOR UTILIZATION OF AN EXISTING SEPTIC TANK
This is to certify that I have inspected the sepnc tank presently sm mg the
{�'I/.(...i)... c rrc� residence located at
t�b�';..t E/., Sectiov 25 ,Town 21 N. Range /`7 W, Town
oC fl��ee.. St Croix County Wisconsin. Upon
mspechon, 1 ce ffy that I have found the tank(s), to the best of my
knowledge, will conform to the requirements of Comm. 84.25, and it (they)
appear(s) to be functioning properly
Most recent date of service
Did Flow back occur from absorption system? Yes_ No_
(if no, skip next line.)
Approximate volume or length of time gallons minutes
Capacity /L?S
Construction Prefab Concrete X Steel Other
Manufacturer (if known) %li—xaj4F7—
Age of Tank (if known): /tS 0�4
qatu U jV 11 -J�CFF 4:;
(Licn ed Plumber S gnatme) (Print Name)
ott MPzs zZ727z
(Title) (License Number) MP/MPRS
(Date)
Form to be completed by licensed plumber (s 145 06, Wisconsin Statutes)
or licensed disposer (NR 113 Wisconsin Adnunistrative Code)
ne�evawdMpnue�� PRNIITE TERRI SYSTEM
INSPECTION REPORT
GENERPLINFORMRTION PTTRCM TO PERMITI
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