13_NCS000559_SCM Inspection Report Template_20220512

TOWN OF CLAYTON
Engineering Department
111 E. Second St., P.O. Box 879
Clayton, NC 27528
Phone: [phone]
Fax:[phone]
ANNUAL INSPECTION REPORT OF STORMWATER CONTROL MEASURE (SCM)
An Annual Inspection Report must be submitted to the Stormwater Administrator of the Town of
Clayton. This form may be submitted in person, by email, by U.S. Mail, Fed Ex, UPS or other mail
service. Failure to submit an Annual Inspection is a violation of the Stormwater Ordinance under which
the project was approved. An Annual Maintenance Inspection and Report must be submitted for each
individual SCM.
SCM INFORMATION:
Project Name:
Address:
Book and Page # of Lot:
Type of SCM (Check One):
AS -BUILT Certification Date:
❑ Bioretention Cell
❑ Infiltration System
❑ Permeable Pavement
❑ Sand Filter
❑ Wet Pond
❑ Green Roof
❑ Other:
LAND OWNER INFORMATION:
Land Owner Name:
Address:
INSPECTION INFORMATION:
Inspection Company:
Inspector Name:
Address:
Think
CLkTO�T
PO Box 879 • Clayton, NC 27528. 919-553-�
919-553-1720 • TownofClaytonNC.org
Project Number:
❑ Dry Pond
❑ Level Spreader -Filter Strip
❑ Rainwater Harvesting
❑ Stormwater wetland
❑ Disconnected Impervious Surface
❑ Treatment Swale
5002
Email:
Phone:
Inspection Date:
Email:
Phone:
Fax

INSPECTION RESULTS:
Inspection results (Check One): ❑ Pass ❑ Fail
Note: A summary of required repairs must be noted on the Annual Inspection Report and submitted to the
Town following completion of a failed inspection. A re -inspection and certification must be completed
within 60 days of the failed report date. It is recommended that the inspector be part of the repair process
to ensure that repairs are being performed properly.
MAINTENANCE RECORDS:
Please include records (or other confirmatory proof) of routine SCM maintenance completed since the last
annual inspection.
COMMENTS:
PROFESSIONAL CERTIFICATION:
To be completed only when the SCMis fuDctioDal with DO outstanding maintenance issues.
I, (Name), as a duly registered (Profession)
in the State of North Carolina, attest that a thorough inspection has been completed for the listed SCM on
(Date). The inspected SCM is performing properly and is in compliance with
the terms and conditions of the approved maintenance agreement required by the Town of Clayton
Stormwater Management Ordinance at the time of development.
Signature:
Affix seal m' box to the right.
Date: