Author: Waalen, Clint

Burnett County Zoning
7410 County Road K, #102
Siren, WI 54872
(715) 349-2138

POWTS
MAINTENANCE
NOTICE

«FIRST_NAME»
«LAST_NAME»
«MAIL_ADDR»
«CITY», «STATE»
«ZIP_CODE»

Private Onsite Waste Treatment System
BURNETT COUNTY MAINTENANCE VERIFICATION CARD
Property Address/Fire #:
Date Tank Components were Inspected or Pumped: _____________________________
Credentialed Person’s Signature and License #: _________________________________
Date the Dispersal Component was Visually Inspected
for Ponding of Effluent on the Surface of the Ground: ___________________________
Credentialed Person’s Signature and License #: ________________________________

«FIRST_NAME»«LAST_NAME»
«MAIL_ADDR»
«CITY», «STATE» «ZIP_CODE»

«YEAR»
«COMPUTER» «PERMIT»

«PROP_ADDR»
«PROP_CITY» «PROP_ZIP»

PRIVATE SEWAGE SYSTEM MAINTENANCE AGREEMENT
The Department of Commerce subchapter V83.54 requires the inspection of all private sewage systems once every three years. The owner of the system must provide this office with verification that the system components have been inspected and pumped if necessary and that the dispersal component has been inspected for the ponding of effluent onto the surface of the ground.
This inspection may be completed by the following credentialed individuals: master plumber, master plumber restricted, certified POWTS inspector and certified septage servicing operators Licensed under ch. NR 114.
Please submit this report within 30 days of pumping so your compliance with the above requirements may be recorded.
INSTRUCTIONS:
Give the attached card to the person responsible for pumping or inspecting your septic system so that he or she can provide the information required.
After servicing, apply the proper postage to the card and return it to this office.
Detach

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Burnett County Zoning
7410 County Road K, #102
Siren, WI 54872

PLACE STAMP HERE