NCS000478_SW O&M Inspection Report_20190812

TOWN OF
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Storm Water
Operations and Maintenance Inspection Report
Stormwater Permit No. SW-
Property Owner/Subdivision Name/Lot Owner
Responsible Party: ❑ Individual ❑ HOA ❑ Other
If HOA, Current President:
Mailing Address:
City: State:
Zip Code:
Phone No. Cell Email
Type of Stormwater being inspected
❑ Dry Detention ❑ Wet Detention ❑ Bio-Retention Area ❑ Constructed Wetland
❑ Underground storage ❑ Level Spreader ❑Rain Garden ❑ Detention Swale
❑ Other
Please Check all Boxes either YES, NO, or N/A.
Has the system been modified from the As Built plans? ❑ yes ❑ No
If yes please describe the modifications.
Do the modifications change the designed capacity and, or the ❑ Yes ❑ No ❑ N/A
designed function of the system?
If the system is located in a common area is there any encroachment ❑ Yes ❑ No
from surrounding property owners on ponds and or easements?

Is there any evidence of erosion at pond overflow spillways, or at downstream toe of drop
structures, or in grass channels or swells? ❑ Yes ❑ No
If the answer to any of the above is yes please describe
Is there evidence of sedimentation build up in any detention / retention areas, ❑ Yes ❑ No
If the answer is yes please describe
In vegetated areas, is there evidence of invasive plant species? ❑ Yes ❑ No ❑ N/A
Is there any visual settlement, or horizontal misalignment of the stormwater dam, ❑ Yes ❑ No
or animal burrows, or cracking, bulging, or sliding of dam?
If the answer to any of the above is yes please describe
Has the pond drain valve been exercised? ❑ Yes ❑ No ❑ N/A❑
What is the overall condition of the facility? ❑ Excellent ❑ Good ❑ Fair ❑ Poor
Please list any maintenance problems or repairs that need to be made immediately or in the near
future to insure the continued proper operation of the stormwater facility.
21Page
FORM 2015-001 REV A

I a licensed to
(Name) (Title)
practice in the state of North Carolina do hereby certify that I inspected the above -named site on
the day of , 20 and that all controls and features
are in compliance with the terms and conditions of the approved maintenance agreement
required by this ordinance.
signature
(seal)
(Name) (Title)
licensed to practice in the state of North Carolina do hereby certify that 1 inspected the above
named site on the day of 120 and
that all controls and features are not in compliance with the terms and conditions of the approved
maintenance agreement required by this ordinance.
signature
FORM 2015-001 REV A
(seal)
3 1 P a g e