NCG550616_Inspection Form_20240521

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Date: ./C u Arrival Time: �.. l� Exit Time: �r
o SINGLE FAMILY WASTEWATER SYSTEM INSPECTION FORM
Permittee: t� l�a, .,� Permit: TJC. 0lollc
Address 11 � nv�g [�f ��4•c"� Email:
Phone( ) Cell Phone { I(0) ?C)Z County: w,
Permittee/Owner YES NO NA NE
1. Is the current resident in the home the permittee?
2. If not,does the resident rent from the permittee?
3.Change of Ownership form needed? % ' 0 '1' ' V,1 hO-'R�► x
4. Is there an inspection and maintenance agreement with contractor?
5. If Yes to#4,who is the contractor?
Septic Tank
6. Is all wastewater from the home connected to the septic tank?
7. Does the permittee/resident know where the septic tank is located?
8. Has the septic tank been pumped in the last 5 years? 5c F
9. If Yes to#8,if known: If proof,describe:
10. Does the septic tank have an effluent filter or sanitary tee?
11. If Yes to#10,when was it cleaned _. _ By whom.
Sand Filtter/Treatment
12. Is system something other than a sand filter?
13. If Yes to#12,what kind? (Ex: peat,textile,Advantix,EZ Treat,etc)
14. Does the permittee know where the sandfilter is located?
15. Does the sandfilter require maintenance?(If Yes,explain in comments)
Disinfection/UV
16. Is UV working?
17. Has the UV unit been serviced and bulbs cleaned or replaced?
18.Who completes the weekly UV check?
Disinfection/Tablets
19. Does the permittee have the correct tablets? X
20. Doest the permittee know the location of the chlorinator?
21.Were chlorine tablets observed in the chlorinator? x
22.Are tablets contacting water?
Dechlorination(discharge only) K
23. Does the permittee know where the dechlorinator is located?
24. Does the permitee have the correct dechlorination tablets?
25.Were dechlorination tablets observed in the dechlorinator?
26.Are tablets contacting water?

ump Tank
7.Is the pump working?
8.Are the audible and visual high water alarms operational?
9. Does the permittee know how to check the pump and high water alarm?
0.Last time tested? Pump: Audible/Visual Alarm:
)ischarge Only
1.Does the permitee know where the outfall is located?
2.Were you able to locate the outfall?
.3. Is the end of the pipe visible and accessible?
14.Is outlet discharging?
15. Is right of way maintained around the discharge point?
16.Are lab results available?
17. Is there evidence of solids around the discharge point?
)rip or Spray L
18.Is the system Drip or Irrigation(circle) If irrigation#sprinkler heads:
39.Are the buffers adequate?
10. Is the site free of ponding or runnoff?
11.Does the application equipment appear to be working properly?
12. Is there a minimum 2 wire fence surrounding entire irrigation area?
13. Is there a rain sensor?
3eneral
14.Are the treatment units locked and secured?
15.Has resident had any sewage problems? (if Yes,explain in comments)
16. Does the system match the permit description? (If No,explain in comments)
47. Is the system compliant?
18. Is the system failing? (if Yes,take pictures if possible)
49.If system is failing,any sign of children or animals contacting sewage?
50.Photos taken?
Comments:
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Inspector:
Signature'