Adeq Report Of Inspection Of An On-Site Wastewater Treatment Facility Page 4
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8REPORT OF INSPECTION
TAX PARCEL NO: ______________ DATE OF INSPECTION:____________
7
G
T
D
W
I
(Complete either Section A or Section B)
ENERAL
REATMENT AND
ISPOSAL
ORKS
NFORMATION
The system consists of the following treatment and disposal technologies (check either column A or column B,
and all applicable boxes in the selected column that describe the overall system).
SECTION A
SECTION B
A) System constructed or authorized for
B) System authorized for construction
ON OR
Construction
January 1, 2001
January 1, 2001
BEFORE
AFTER
Conventional Septic Tank System
GP 4.02 Conventional Septic Tank/ Disposal System
Septic Tank
Septic Tank
Disposal Trench
Disposal Trench
Disposal Bed
Disposal Bed
Disposal by Chamber Technology
Disposal by Chamber Technology
Disposal by Seepage Pit
Disposal by Seepage Pit
Other:
Alternative Systems (check all that apply)
Alternative Systems (check all that apply)
Composting Toilet System
GP 4.03 Composting Toilet System
Pressure Distribution System
GP 4.04 Pressure Distribution System
Gravelless Trench
GP 4.05 Gravelless Trench
Natural Seal Evapotranspiration Bed
GP 4.06 Natural Seal Evapotranspiration Bed
Lined Evapotranspiration Bed
GP 4.07 Lined Evapotranspiration Bed
Wisconsin Mound
GP 4.08 Wisconsin Mound
Engineered Pad System
GP 4.09 Engineered Pad System
Intermittent Sand Filter
GP 4.10 Intermittent Sand Filter
Peat Filter
GP 4.11 Peat Filter
Textile Filter
GP 4.12 Textile Filter
Denitrifying System Using Separated Wastewater
GP 4.13 Denitrifying System Using Separated
Streams (e.g., RUCK®)
Wastewater Streams
Sewage Vault
GP 4.14 Sewage Vault
Aerobic System
GP 4.15 Aerobic System
Nitrate-Reactive Media Filter
GP 4.16 Nitrate-Reactive Media Filter
Cap System
GP 4.17 Cap System
Constructed Wetland
GP 4.18 Constructed Wetland
Sand-Lined Trench
GP 4.19 Sand-Lined Trench
Disinfection Devices
GP 4.20 Disinfection Device
Surface Disposal
GP 4.21 Surface Disposal
Subsurface Drip Irrigation Disposal
GP 4.22 Subsurface Drip Irrigation Disposal
Design flow is 3,000 gpd or more
GP 4.23 Design flow from 3,000 to less than 24,000
Other
Gallons Per Day (4.23 GP)
Date of Construction:
Date of Discharge Authorization for system
Based on:
(or Verification if issued from 1/1/2001 through 12/11/2005):
Permitting documentation
Other documentation
Estimated
Unknown Construction Date
C) Date of last inspection and/or pumping of septic tank:
_________ / _____ / __________
Unknown
D) Repairs or alterations to the facility since original installation?
Yes
No
Unknown
E) Is facility currently being serviced under a maintenance contract?
Yes
No
Unknown
F
GWS 432 (R
,
16, 2007)
P
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ORM
EVISED
FEBRUARY
AGE
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