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Home My WebLink AboutSP2011194 2-1 MFGRANT COUNTY CONSERVATION, SANITATION & ZONING DEPT. 150 W Alona Ln, Suite #1, Lancaster WI 53813 Phone: (608)723-6377 ext. 4 sanitation(a7co.grant. wi.gov Septic System Maintenance Report Maintenance Fee is $25.00, or $100.00 if received after September 30, 2023 Checks payable to: Grant Co. CSZD ALCORN TRUST DATED 4/25/1997 9554 GRAYS MILL RD LANCASTER WI 53813 Tax Parcel: 002-00001-0000 Township: TOWN OF BEETOWN Property Address: 9554 GRAYS MILL RD Sanitary Permit: 2011-2011194 The Grant County Private On -site Wastewater Treatment Systems(POWTS) Ordinance & Wis. Adm. Code SPS 383.50 - 383.55 require that all POWTS be inspected every three years to ensure proper operation and public health safety. Please contact a Licensed Service Provider to schedule your evaluation. For a list of providers and additional homeowner information, please visit our website at www.co.grant.wi.gov. A Service Provider Licensed by the State of Wisconsin must complete this form. Tan • Evaluations must include a visual inspection identifying any missing or broken hardware, cracks or leaks. Concrete, ( ] Metal, I ] Plastic or Fiberglass ] Tank(s) Not Pumped, POWTS evaluated & accumulated sludge/scum volume less than 1/3 of tank volume Tank(s) Pumped and POWTS Evaluated Gallons Pumped Tank #1 1300 gal. #2 gal YES NO N ALL tanks appear to be water tight & functional? N ALL tank risers appear water tight & functional? N ALL tank baffle(s) in -place & functional? N ALL tank riser covers secured? (chained and locked) N The filter is clean & functioning? or NIA If not equipped. N ALL tank components operational? (Pumps, alarms, ext.) or NIA If not equipped. Dispersal Cell: The dispersal cell shall be visually inspected to check for backups or surface discharge. stem Type: (Pressurized) (Mound) �t-grade) Other: N ALL observation & vent pipes were intact and functional? The distribution box is functioning correctly? or NIA If not equipped Y Surface discharge observed? (Tank) (Drain field) (Outfall pipe)? Other Identify areas of concern and explain items marked as "no" above: POWTS EVALUATION SERVICE PROVIDER VERIFICATION Responsibility Statement: I, the undersigned, certify that the data reported on this form was obtained by me and is correct to the best of my knowledge and ability: Name (print)%/%% �/"%,r� Signature Cert. # W ✓,�, Phone # Date of Services: &—a—dw.. Dept. Use Only: ia' unctional 0 Failing Reviewed by: Date 2023mf RECEIVED IN 0 7 2023 GRANT COUNTY CONSERVATION, SANITATION & ZONING DEPT. 150 W Alona Ln, Suite #1, Lancaster WI 53813 Phone: (608)723-6377 ext. 4 sanitation@co.grant.wi.gov Septic System Maintenance Report Maintenance Fee is $25.00, or $100.00 if received after August 31, 2020 Checks can be made payable to: Grant Co. CSZD ALCORN TRUST DATED 4/25/1997 9554 GRAYS MILL RD LANCASTER WI 53813 Township: TOWN OF BEETOWN Property Address: 9554 GRAYS MILL RD Tax Parcel: 002-00001-0000 Sanitary Permit: 2011-2011194 Your septic system is due for maintenance this year. The Grant County Private On -site Wastewater Treatment Systems(POWTS) Ordinance & SIPS 383.50 & SPS 387 Wis. Adm. Codes require that all POWTS be maintained to insure proper operation and public health safety. All systems must be evaluated and/or pumped every three years. Please contact a Licensed Service Provider soon to schedule your evaluation. Visit www.co.grant.wi.gov for a listing of plumbers/pumpers. Scheduling late in the season may result in weather related delays, pumpers operating at full capacity, and State restrictions on volume accepted at local sewer plants. Tank evaluations must include a visual inspection to identify any missing or broken hardware, cracks or leaks. If the combined accumulation of sludge/scum in any treatment tank equals (1/3) or more of the volume, the entire contents of the tank shall be pumped. The dispersal cell shall be visually inspected to check for backups or surface discharge. A Licensed Service Provider m irm & return within 30 days of service. Tank: kiConcrete, [ ] Metal, [ ] Plastic or Fiberglass [ ] Tank(s) Not Pumped, POWTS evaluated & accumulated sludge/scum volume less than 1 3 of tank volume Tank(s) Pumped and POWTS Evaluated Gallons Pumped Septic Tank i# � 00_gal. #2 gal S No N ALL tanks appear to be water tight & functional? N ALL tank risers appear water tight & functional? N ALL tank baffle(s) in -place & functional? N ALL tank riser covers secured? (chained and locked) N The filter was clean & is functioning? or N/A if not required at time of installation. Y N ALL tank components were operational? (Including pumps, alarms, electrical components, ext.) Drain Field: (Pressurized) (Mound) n-groun (At -grade) Other: N ALL observation & vent pipes were in act and functional? N The distribution box was functioning correctly? or NIA If not "D" box equipped Y ® Surface discharge observed? (Tank) (Drain field) (Outfall pipe)? Other Identify any failing component or areas of concern: POINTS EVALUATION SERVICE PROVIDER VERIFICATION sponsibility Statement: I, the undersigned, certify that the data reported on this form was obtained by and is correcthe best of my knowledge and ability: ` 2 Name (print) n ' Signature Cert. # Q ,IqI Phone # �JJ )' I Date of Services: PUMP or INSPECTED:[] kECEIVED APR 2 12020 Dept. Use Only: )(Fnc'tional 0 Failing Reviewed by: Date 2024mf GRANT COUNTY CONSERVATION, SANITATION & ZONING DEPT. 150 W Alona Ln, Suite #1, Lancaster WI 53813 Phone: (608)723-6377 ext. 4 sanitationgco.grant.wi.gov Septic System Maintenance Report Maintenance Fee is $15.00, or $100.00 if received after August 31, 2017 Checks can be made payable to: Grant Co. CSZD ALCORN TRUST DATED 4/25/1997 9554 GRAYS MILL RD LANCASTER WI 53813 Township: TOWN OF BEPTOWN Property Address: 9554 GRAYS MILL RD Tax Parcel: 002-00001-0000 Sanitary Permit: 2011-2011194 Last Maintenance: 08/25/2014 Your septic system is due for maintenance this year. The Grant County Private On -site Wastewater Treatment Systems (POWTS) Ordinance & SIPS 383.50 & SPS 387 Wis. Adm. Codes require that all POWTS be maintained to insure proper operation and public health safety. All systems must be evaluated and/or pumped every three years. Please contact a Licensed Service Provider soon to schedule your evaluation. Visit www.co.grant.wi.gov for a listing of plumbers/pumpers. Scheduling late in the season may result in weather related delays, pumpers operating at full capacity, and State restrictions on volume accepted at local sewer plants. Tank evaluations must include a visual inspection to identify any missing or broken hardware, cracks or leaks. If the combined accumulation of sludge/scum in any treatment tank equals (1/3) or more of the volume, the entire contents of the tank shall be pumped. The dispersal cell shall be visually inspected to check for backups or surface discharge. A Licensed Service Provider must complete this form & return within 30 days of service. "[yti Tank(s) Not Pumped, POWTS evaluated & accumulated sludge/scum volume less than 1/3 of tank volume [ ] Tank(s) Pumped and POWTS Evaluated Gallons Pumped Septic Tank 1# gal. #2 _gal #3 gal C5 NO YI N ALL tanks appear to be water tight & functional? Y N ALL tank risers appear water tight & functional? Y j N ALL tank baffle(s) in -place & functional? Y N ALL tank riser covers secured? (chained and locked) Y N The filter was clean & is functioning? or NIA If not required at time of installation. Y N ALL tank components were operational? (Including pumps, alarms, electrical components, ext.) rain field type: (Pressurized) (Mound) (In -ground) (At -grade) Other: Y N ALL observation & vent pipes were intact and functional? Y -N The distribution box was functioning correctly? or NIA If not "D" box equipped Y Surface discharge observed? (Tank) (Drain field) (Outfaii pipe)? Other Identify any failing component or areas of concern: POWTS EVALUATION SERVICE PROVIDER VERIFICATION Responsibility Statement: I, the undersigned, certify that the data reported on this form was obtained b a c re to .he best of my knowledge and ability: 1 .! t�'� � - Name (print) �I 1a� nature Y Cert. # Phone # �./ g Date of Services: -� - �`� PUMPED: [ ] or INSPECTED:.( 1 Dept. Use Only: XFunctional O Failing Reviewed by: U{./ Date 2016mf RECEIVED AUG 2 9 2017 GRANT COUNTY CONSERVATION, SANITATION & ZONING DEPT. 150 W Alona Ln, Suite #1, Lancaster WI 53813 Phone: (608)723-6377 ext. 4 sanitation(cDco.grant.wi.gov Septic System Three Year Maintenance Report Due Date: AUGUST 31, 2014 March 19, 2014 ALCORN TRUST DATED 4/25/1997 9554 GRAYS MILL RD LANCASTER WI 53813 Township: TOWN OF BEETOWN Property Address: 9554 GRAYS MILL RD Tax Parce!: 002-00001 0000 Sanitary Permit: 201.1-2011194 Last vialntenanee: The Grant County Private Onsite Wastewater Treatment Systems Ordinance & SPS 383.50 & SPS 387 Wis. Adm. Codes require that all Private Onsite Wastewater Treatment System be maintained to insure proper operation & thereby protecting the public health. The property owner is responsible for obtaining the maintenance evaluation for their septic systems. The Grant County Board of Supervisors approved an administrative filling fee of $15.00 for this document. The $15.00 fee must be included with this report to be accepted. Please make check payable to Grant Co. CSZD. If not received by the due date an additional late fee of $10.00 will be charged. Please contact a Licensed Service Provider to evaluate your tank(s) & dispersal cell(s). The Service Provider must complete this form & return it to the Grant Co. CSZD within 30 days of date of service Tank evaluations must include a visual inspection to identify any missing or broken hardware, cracks or leaks, to measure the volume of combined sludge & scum and to check for any backups or surface discharge. The dispersal cell shall be visually inspected to check for backups of effluent within the cell or surface discharge. If the combined accumulation of sludge & scum in any treatment tank equals (1/3) or more of the tank volume, the entire contents of the tank shall be pumped. Servicing of pretreatment units must be performed by a certified POWTS maintainer. To be completed by a Licensed Service Provider [) Tanks not Pumped, POWTS was evaluated & accumulated sludge & scum volume less than 1/3 of tank volume Tank(s) Pumped and POWTS Evaluated Gallons Pumped Septic Tank 1# ZO M gal. #2 lal7C'-) gal #3 gal YES NO N ALL tanks appear to be water tight & functional? N ALL tanks risers appear water tight & functional? N ALL tank baffle(s) in place and functional? Y IV ALL tank, riser cover's) secured? N The filter was clean & functioning? or NIA If not required at time of installation. N ALL tank components were operational? (Includ�l�umps, alarms, electrical components, ext.} Drain field type: (Pressurized) (Mound) (In-groun At- r de Other: (� N ALL observation & vent pipes were intact and functional? The distribution box was functioning correctly? or NIA If not "D" box equipped Y LN Surface discharge observed? (Tank) (Drain field) (Outfall pipe)? Other Identify any failing component or areas of concern: POWTS EVALUATION SERVICE PROVIDER VERIFICATION R data reported on this form was obtained by m Ind � r Name (print)Al < �i� Signature Date of Services:. -Z —j �;� PUMPED: _ sibility Statement: I the undersigned, certify that the t�e best of my knowledge and behalf: Bert. # 161 `t`—r Phone # 'Z LJd i or INSPECTED: Dept. Use Only: .Eu Tinnal 0 Failing Reviewed by: 43. Date RECEIV `2B1JEP 0 2 2014