Civitan Park Wetland 2021 Inspection Form Completed

City of Winston-Salem Stormwater Division — Stormwater Post Construction Permit
Annual Compliance Report
Development Name: 61 V ITP*%�k PA(A( WVEEL Permit No: tom( )ry
Contact Person: - (�.G .r Phone Number: ^3-3 G_ -1 *7— 6q 6 1
Inspection Year (e.g. June 2019-May 2020): Z )
Development Address: tsFF rgLu V�Np C�r6L ot�
Permit Information
Stormwater Management System Addresses (circle one): Water Quality Water Quantity Both
Stormwater Control Measures (SCM's) Inspected in the past year applicable to this site (insert nun ex of ea
_Wet Ponds Infiltration Basins Infiltration Trenches Swales Stormwater Wellar
Dry Ponds Bioretention Cells Permeable Pavement Sand filters (circle one — pe Closed
Underground Cistem/Piping Detention System _Level Spreader/Filter Strip Bay Filters Contech Filters
Other (specify type and number on site):
File Review - Notification of Chances etc. Yes No N/A
1. Is the development still consistent with the approved set of as -built records? (Have additions been made to
the site which have increased the impervious area for example but for which the City Stormwater Division
was not notified
2. In the case of a HOA has the contact person for the BOA changed since the time of the recorded O&M
Agreement? If so please provide the new contact for the HOA in a later section of this report
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3. Has the ownership of the system changed since the O&M Agreement was recorded?
4. Has the City of Winston-Salem Stormwater Division been notified of any owner changes and have the
appropriate procedures been followed for such change in ownership per the O&M Agreement
requirements?
Built lJnen Area l6LJA1
Yes No N/A
5. Is the BUA still consistent with the permitted design or have other constmction activities occurred
without the Stormwater Divisions knowledge?
✓
6. Is the BUA aspermitted) graded such that the runoff drains to the system?
✓
7. Is the drainage area still consistent with thepermit? i.e. no un ermitted drainage to the SCMS
✓
8. Is the drainage area stabilized? to reduce risk of sedimentation to the SCM's)
✓
Stormwater SCM's - Cenaral
Vas No N/A
9.
Are the
SCM(s) still located per the approved plans?
r/'
10.
Are [he
SCM s s ecifications still matchin the ermitted Tans?
11.
Have any un ermitted changes or modifications been made to the SCM(s)?
12.
Are the
Riparian buffers recorded during permitting if applicable) free of disturbance & built upon area?
Stormwater SCMtsI - Oneration and Maintenance
Yes No N/A
13. Are the recorded Stormwater Access and Maintenance Easements, or general access to the site and the
system in the case of a blanket easement, clear and well maintained?
14. Are the SCM(s) been operated and maintained per thepermit/recorded O&M Agreement requirements?
15. Have all of the SCM(s) inspections carried out in the past year been carried carper the required frequency
as stated in the O&M Agreement and copies of those inspections provided here with this annual report?
16. If the inspections necessitated any maintenance of the SCM(s) has all such documentation of maintenance
been provided here as in what the issue was, who carried out the maintenance/repairs, when was it done
along with photographic evidence of before and after repairs?
Ciry of Winston-Salem Stormwater Division —Stormwater SCM(s) Annual Compliance Report
Page 1 of 2

City of Winston-Salem Stormwater Division — Stormwater Post Construction Permit
Annual Compliance Report
SCM s Ins ectors
Yes No N/A
17. Have all of the past years inspections of the SCM(s) been carried out by a suitable qualified professional
such as a Registered Engineer or Landscape Architect in the State of North Carolina, or an individual who
has attained certification to inspect SCM(s) through North Carolina State University's SCM Inspection
course? Documentation of such credentials must be included with the annual inspection records submitted
with this report and should include. the name, their contact address and phone number and proof of their
qualifications to carry out such inspections such as seals attached to the inspections or photocopies of
their NC State certification.
Ins ection Photo ra hs — **Re ulred to be submitted with annual Ins ection re orts** Yes No NIA
18. Are ail relevant photographs [akeh during
[he individual
inspections
and if applicable, maintenance
activities, included here in with this report
submittal and
do all these
photographs have date stam s?
Comments -Please list or include below any other comments that you may see as relevant to this submittal of records.
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AG.Gk>S is I✓APotstQt_E O k� kry fc)t,%0E
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Ownershio Information -Provide the latest owner and/or HOA contact person name, address and phone number below.
Please note that if changes to ownership were made without the City Stormwater Division been made aware of it, then the
original owner and the new owner must immediately address and comply with the O&M Agreement item that details transfer
of ownership and request that the Stormwater Division reissue the permit to the new owner. Please state if this is the case
Financial Statement of Escrowed Funds - If a HOA is involved in the ownership of this Stormwater management system
then this means there was an escrow account established at the time of permitting. The HOA is obliged to add funds to this
account per the Post Construction Stormwater Management ordinance and O&M Agreement/Escrow Agreement
requirements and to maintain such funds in this account. A most recent financial statement of escrowed funds should be
attached here to this report
Financial Statement Attach d ❑ Yes ❑ No (If no explain why not and when this statement will be provided)
iJ rA
Compliance Status ❑ Compliant � Non -Compliant
If non -compliant with any aspect of the permit and its O&M Agreement please provide additional documentation, plan of
action etc. of how and when the non -compliant issues will be addressed.
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Inspector Name and Signature:T scDK �o(n+lLTy/� 'cam- -ram'*, pate:
Inspector Qualifications:
(State NC License Number
to this report or include a copy of NC State SCM Inspector Qualifications)
City of Wius[on-Salem Stormwater Division — Stormwater SCM(s) Auuual Compliance Aeport
Page 2 of 2

STORMWATER WETLANDS: O & M Inspection Checklist
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V�L�IJavO "TbT91l j u 2vwY� —Npr V)Cc(Si�IL YES NO NIA fLVZ,n4
INLETS and FOREBAY
1. Inlets are located per the approved plans: = r\( Jq , N 7 i S ❑ ❑
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2. Inlet device (swale or pipe) is free of erosion, damage or clogs: ❑ ❑ L�'
3. Forebay berm is in place and without erosion: ❑ ❑ j
4. Energy dissipaters such as rip -rap aprons and plunge pools are in place and functioning: ❑ ❑ il:l�
5. Forebay is free of excessive sediment: L e7u L,p 6Vv1A �i ZVL ❑ �/
6. Forebay is free of trash: ",,tea „,vykq , t ryD ❑ 14� ❑
SIDE SLOPES AND BANKS
7. Vegetated side slopes are no steeper than 3:1: (LOA" T TL &L(_ ❑ ❑ LJ2
8. Banks are stable and free of erosion or bare soil: r ' " ❑ ❑ LLk
9. Slopes or berms are free of woody vegetation: ❑ ❑
10. Free of muskrat or beaver activity: 1 K,-wdl0 .Sovne GRiTT l:� ``S lYNl'(NL ❑ LP� ❑
11. Plants are healthy and being maintained: -Tw ❑ i U� ❑
12. Shallow land is free of flooding at 5 days after rain event (should draw down in 2-5 days): ❑ ❑
G�hv7 TL�u
13. Main treatment area is free of excess sediment accumulation: cva ti"-c -rLa.L _ Exiqe4T nra ❑ Ljz� ❑
14. Main treatment area is free of trash and other debris: rr-w r i Lqq . - e� xa %&T nso ❑ D� ❑
15. Algal growth covers less than 25% of the basin surface area: cr&r T Ttp7 . - t c ST ❑ ❑ J:le
16. Cattails, phragmites or other invasive plants cover ss than 25% of the basin surface area: ❑ ❑
17. Access easement Is being maintained: ❑ f� ❑
OUTLETS AND OUTLET DEVICE
18. Swale or emergency outlet bypass (spillway) is in the correct place and in good condition: ❑ ❑ L�
GA4�T 7�u 19. Spillway has correct ground cover as per approved deviceje.g. vegetated or rip -rap): ❑ ❑ Lp'
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20. Deep pool near outlet is free of vegetation: GAT ❑ ❑ -Er
21. Drawdown device is correctly sized free of damage or clogging: GA'�T Ac c s5 ❑ ❑
22. Drawdown valve (if applicable) is closed and not leaking: GMvr ac�e,056 ❑ ❑
23. Orifice size matches the approved plans and is not dogged: 6AVi T Ac.�L SS ❑ ❑ kfr
24. Outlet riser (if applicable) is structurally sound and not leaking: e44Irvr Acr E% ❑ ❑ QJ
25. Weir size matches the approved plans and is not clogged or damaged: crvVT AccE5S ❑ ❑ e
26. Area at outlet is free of erosion, clogs or other signs of damage: Gv'"T A c ecE, SS ❑ ❑ 4?f
27. Energy dissipater at outlet is in place and functioning: (zv.r C Ikwc ❑ ❑ 0'
28. Trash rack is provided: G/}NZ AcZ�GSS 0 ❑ 0

29. The vegetated filter and level spreader is in place (if applicable): ❑ ❑ kL2'
30. Vegetated filter strip and level spreader inspection form completed (if applicable): ❑ ❑ LD-
31. Relative elevations match the approved plans: C. M T Try Lam' ❑ ❑
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Note: If there is more than 1 wetland on the property then a separate inspection checklist must be completed for each
wetland. The Inspector should note on each checklist which wetland the inspection form refers to and describe its location on
the property
(t)
Date of Inspection
Name of Inspector (Please type)
Sigature of Inspector
Qualification of Inspector (Please describe your credentials/qualifications to carry out this inspection below)