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INSPECTION REPORT
TANK SETBACK INFORMATION
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DATE
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ST CROIX COUNTY WRING OFFICE
CERTIFICATION
NT
FOR UTILIZATION OF AN EXISTING SEPTI
C TANR
This iT�co certify that t have inspected tM1a Septic tank presently ee ving
the L_pU GO N ��p
Sec_ residence located at: N N �. T N, R �4 W, County, Wisconsin, Tarn of Upon ins �y inspection, St. oix
, I certify that I have found the tan and
baffles to be in good c a
Wet time Serviced ondsi aUll(1 it
appea re to be functioning props 1 l / Y.
Did flow back occur from absorption system] yea_ NOJ
line. Uf no.
skip exc
Approximate volUna or length o£ time;
Capacity: gallons minutes
Construction P� re RE Concrete
Manufacturer lif known); Steel other
Age of Tank (if known):
(4lcenee Number
feats a
Form to be completed by licensed plumber (a. 145.06, Wisconsin Statutes)
l iceneed disposer ME 113 Wisconsin Administrative Code)
Plumber (applying for sanitary permit) Certification.
In accepting the above statement
certify that the tank, to the baOregarding emy xisting septic tank condition
requirements of ILNR S3, WIS. Adm. Code knowledge, will conform to
outlet baffle). (except fo s
n 1 n p cion opening o
Name O 4Yr]pP fr-
�'—� signature
WP/MPRB Oon n
or
LE PAP
TEN
FOR APRON RELATIONS INSPECTION REPORT FOR MPET. a EWmIN"
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