Completed 2021 Inspection Forms_Washington Dog Park

City of Winston-Salem Stormwater Division — Stormwater Post Construction Permit
Annual Compliance Report
Development Name: yv A 5 4t tN -pcNJ P,A,IZ\Of' _ 510 C. G LL Permit No: t i 1 A
Contact Person: -So 5e,pv� Fo Ca�R rl VE Phone Number: 3U 14,-(_ 6i 61
Inspection Year (e.g. June 2019-May 2020): ao � � — Zo22
Development Address: 1 P%S1N%NgTd 4w4fL . w.nfSTcw— SR1.C�1. IIJ G
Permit Information
Stormwater Management System Addresses (circle one): 0ater Quali Water Quantity Both
Stormwater Control Measures (SCM's) Inspected in the past year applicable to this site (insert number of each):
Wet Ponds a ' n Basins Infiltration Trenches Swales Stormwater Wetland
_Dry Ponds 9.. Bioretention Celts Permeable Pavement Sand filters (circle one) — Open/Closed
Underground is er . rping Detention System.Level Spreader/Filter Strip Bay Filters _Contech Filters
Other (sped type and number on site):
File Review _ Nntifiratinn of Channes atr._
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 BOA 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 BOA in a later section of this report
V
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?
Ruilt Ilnnn Area fRl1A1
Yes No N/A
5.
Is the BUA still consistent with the permitted design or have other constmction activities occurred
without the Stormwater Divisions knowled e7
✓
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 errnitted drainage to the SCMs
8.
Is
the
drainage area stabilized? to reduce risk of sedimentation to the SCM's
Stormwater SCM's -General
9.
Are the
SCM(s) still located er the a proved lans7
✓
] 0.
Are the
SCM s ecifications Brill matching the ermitted lans7
✓
11.
Have any un ermitted changes or modifications been made to the SCM(s)?
1
✓'
12.
Are the
Riparian buffers recorded during permitting (if applicable) free of disturbance & built upon area?
Stormwater SCM(s\ - Operation 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 the ermit/recorded O&M A reement re uirements7
✓
15. Have all of the SCM(s) inspections carried out in the past year been carried out per 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 docdmentation of maintenance
been provided here as in what the issue was, who carried out the maintenance/repairs, when was it done
�oe
City of Winston-Salem Stormwater Division-StonnwatwSCM(s) Mnual Compliance Report
Page l of2
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City of Winston-Salem Stormwater Division - Stormwater Post Construction Permit
Annual Compliance Report
SCM(s) Inspectors
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
r/
�
V
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. N oNt D awl t W DA'ST 'gv er '(q is
wryCALItAOU CHN 1k'++ic
Inspection Photographs — "Required to be submitted with annual inspection reports" Yes No N/A
18, Are at l relevant photographs taken during the individual inspections and if applicable, maintenance ✓
activities, included here in with this report submittal and do all these photographs have date stamps?
Comments -Please list or include below any other comments that you may see as relevant to this submittal of records.
Please add and attach additional sheets to the back of this report if more room is necessary:
r3+d- c.t-w is CwsnPu.t.Tt��( csv�2o..+t�1_F+w2'o -ro sEt,l.wN1�S IMVASt1l� oR.
9w'ccam#gc7ry aemcNiJrt, op `titZAs a Pt,.(W+ XC1 8 R Pt.Acsn eN=j w1TK scr
t"4 \T N A " %ram r P Sop Is
KapDiSS Do rvut Fe(L'rILIZE it Swr n1
Ownership 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
also below and when the Stormwater Division can expect to be notified.
!J' A — G\ T`i Ow�r'� M .sN \ G \ P P'l. S (.1^/1
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 Attached ❑ Yes ❑ No (If no explain why not and when this statement will be provided)
t41K1 — MJNle kf l,, Se m
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.
wr\.to $E Th �EPA(rrMIWT `^'tt�rvAc,e+�l�nlT IJv GaMt+vr) v 5
—TW5%t w %L4t FecN iDe T(� 'rKU P L^r° 1 ofr AC 7t aU
Inspector Name and Signatu
Inspector
Quacations:
(State NC
License Number and
attach
seal to this
report or
include a copy of NC State SCM Inspector
City of Winston-Salem Stnrmwxter Division —Stormwater SCM(s) Annual Compliance Report
Page 2 of 2

BIORETENTION CELL: O & M Inspection Checklist
INLET and PERIMETER
1. Inlet and Perimeter are free of erosive gullies and bare soil areas:
2. Inlet device (swale, pipe, stone verge) is free of erasion, damage or clogs: 0000 ❑ ❑
3. Weir heights appear to match approved plans: t ❑ ❑
PRETREATMENT/ FOREBAY
4. Flow is entering pretreatment area (not being bypassed): je;� ❑ ❑
5. Pretreatment area is free of erosion: p ❑ ❑
6. Level Spreader (if applicable) is structurally sound and remains level: ❑ ❑ cq�
7. Pretreatment area Is free of excessive sediment or clogs: ❑ ❑ J�
8, Energy Dissipaters (rip rap aprons/plunge pools) are correct size and functioning: ❑ ❑
9. Pretreatment area is free of trash and other debris: ❑ ❑ 1�
MAIN TREATMENT AREA
10. Vegetated side slopes are no steeper than 3:1: ❑ ❑
11. The under drain system is free flowing and free of clogs (if applicable): (APtc-a2STo Be) 2' ❑ ❑
AppoNLS To Ism $J= SO &jii &f t+ 3
12. Main treatment area is free of sediment: t tb NA(Lv To soz ea�' -qt6 CP C& FUt L❑ ❑
13. Cleanout(s) and cap is provided for the under drain as per the approved plans: J20' ❑ ❑
14. Cleanouts(s) and caps free of damage potentially caused by mowing/mafntenance: ❑ ❑
15. Heavy equipment has not been driven Into the cell: LFo�r ❑ ❑
16. The "Do Not Fertilize" signs are still in place and visible for sodded cells: ❑ ❑ L000
17. Surface is free of piles of heavy materials (piles of mulch, etc): JL2` ❑ ❑
18. Ponding depth is 9-12 inches after rain: gVeK ❑ ❑
19. All dimensions are >=10ft.: Le�� ❑ ❑
20. Main treatment area is free of trash and other debris: ❑ ❑
21. Access easement is being maintained: L� ❑ ❑
SOIL/MULCH/SOD and VEGETATION
22. Plants are healthy and being maintained: �foTALL.y ❑ vO' ❑
23. The proper amount and type of vegetation/plantings is present In the cell: CAS ,AGc:P%& ❑ P' ❑
24. Mulch (if applicable) is in good condition (has not broken down or floated/migrated towards the outlet):
❑ ❑
25. Surface if free of excessive sediment and clogs: vE� ❑ ❑
26. Sod (if applicable) is in good condition and free of weeds and bare spots &�TAL y ❑ , ❑
pyZyL JjyjV„vN�
27. Trees are free of stakes/wires > 6 months after planting: ❑ ❑ uV

28. Ponded volume drains completely into the soil layer within 12 hours: `hp000kS To) Jd ❑ ❑
29. Ponded volume drains completely from the device within 48 hours: (toCh9L+4 a' , Fee r ❑ ❑
30. The annual soil test shows the proper pH and absence of heavy metal accumulation ❑ ❑ 9'
OUTLET
31. Outlet is free of evidence of improper drainage (no standing water, cattails, etc.): C200 ❑ ❑
32. Outlet device (drop inlet, weir, etc.) is free of damage or clogs: � me ❑ ❑
33. Orifice size matches approved plans: F' ❑ ❑
34. Outlet Is free of damage, clogs, or erosion: LFoK ❑ ❑
35. Outlet Energy dissipater is correct size and functioning (if applicable): ❑ ❑ �;V
36. Relative elevations match approved plans: W ❑ ❑
Note: If there is mare than 1blo-retention cell on the property then a separate inspection checklist must be completed for
each bio-cell The inspector should note on each checklist which cell the inspection form refers to and describe its location on
the property
\1—o5-lea-1
Date of Inspection
S o5i:.�-1 FoGA,R—C� 'PAC
Name of Inspector (Please type)
Qualification of Inspector (Please describe your credentials/qualifications to carry out this inspection below)