INSTRUCTIONS FOR PREPARING A REPORT OF INSPECTION
INSTRUCTIONS FOR PREPARING AREPORT OF INSPECTIONFOR AN ON-SITE WASTEWATER TREATMENT FACILITYINSTRUCTIONSAny person selling or transferring ownership of aproperty served by an on-site wastewater treatmentfacility (including a conventional septic tank system orand alternative on-site wastewater treatment facility)must retain a qualified Inspector to inspect the facilitywithin six months prior to transferring ownership of theproperty, (Arizona Administrative Code, A.A.C. R18-9A316). See Figure 1.An inspector that is qualified under A.A.C. R18-9A316, must complete the attached Report of Inspectionform, and provide it to the seller as required by theCode. If there is more than one on-site system in useon the property, the Inspector shall complete a Reportof Inspection form for each system.Qualified Inspector inspects facilitywithin 6 months before property transferInspector completes Report of Inspectionand gives to SellerPrior to property transfer, Seller gives Report ofInspection to Buyer with any other facilitydocumentation in Seller’s possessionBuyer submits Notice of Transfer formwith fee to applicable agencywithin 15 days after date of property transferBefore the transfer date (closing date) of the property,Figure 1. Flowchart of Notice of Transfer Process.the seller shall provide the buyer with the completedReport of Inspection form and any other documents in their possession that relate to the permitting or operationand maintenance of the septic tanks systems or alternative on-site wastewater treatment facility. DO NOTsubmit this Report of Inspection form to ADEQ or the local county permitting agency. The Buyer retainsthis form after receiving it from the Seller.Within 15 calendar days after the date of property transfer, the Buyer shall submit a complete Notice of Transferform ad/presale.doc) for the change of ownership, and fileit with the applicable agency indicated in the Notice of Transfer instructions. Information from this Report ofInspection form is needed to fill out the Notice of Transfer that must be submitted by the Buyer.Effective February 2, 2007, you may be able to file your Notice of Transfer online. Go to the ADEQ website at ot.html for further information regardingthis.Qualified inspectors are required to completely and accurately fill out this form to the best of their knowledge.FORM GWS 432 (REVISED, FEBRUARY 16, 2007)DOWNLOAD THE LATEST UPDATE OF THIS FORM FROM THE ADEQ WEBSITE oad/inspection.docPAGE i
REPORT OF INSPECTIONOF AN ON-SITE WASTEWATERTREATMENT FACILITY1PROPERTY INFORMATION (All fields are required)Address23CityCountyTax Parcel No.Residential propertyCityZipZipCURRENT OWNER INFORMATION (All fields are required)NameMailing AddressStateINSPECTOR INFORMATION (All fields are required)Inspector NameCompany NameAddressNon-residential propertyNAWT Inspector No.Phone No.4FaxEmailINSPECTOR QUALIFICATIONS (Inspectors must fill out Section A, and check at least one box in Section B)A. Coursework requirementName of ADEQ-approved Course:City where Course was takenB. License/Registration (check at least one box)Date Completed:Registration/License No.ExpirationDateOwner of a vehicle with a Human Excreta Collection and TransportationLicense (a Septage Hauler license), issued pursuant to A.A.C. R18-13-1103.Owner of license;Employee of licensed ownerCheck one:Wastewater Treatment Plant Operator licensed pursuant to A.A.C. R18-5Grade 1;Grade 2;Grade 3;-101 through 116 (indicate type):Grade 4Arizona Registered SanitarianArizona Professional EngineerLicensed Contractor (indicate type):Residential B-4 or C-41;Commercial A, A-12, or L-41; orDual KA or K-41A person qualifying under another category designated by the Department (describe)5DOCUMENTS CONSULTED (Answer as applicable)NoYes (indicate below)Were facility permit, construction and/or operational records available?A)YesNo Discharge Authorization (or Verification) issued on or after January 1, 2001 pursuant toR18-9-A301(D)(2)(c). If yes, indicate agency File No: and date issuedB)YesNo Approval of Construction issued by ADEQ or its delegated County agency before January 1,2001. If yes, indicate agency File No. and date issuedYesNo Site plan, plot plan, “as-built” drawings, or similar documents (describe):C)D)E)YesYesNo Documents relating to operation and maintenance (alternative systems)No Other (describe):FORM GWS 432 (REVISED, FEBRUARY 16, 2007)DOWNLOAD THE LATEST UPDATE OF THIS FORM FROM THE ADEQ WEBSITE oad/inspection.docPAGE 1 OF 7
REPORT OF INSPECTION6TAX PARCEL NO: DATE OF INSPECTION:SITE AND USAGE INFORMATION (All fields are required)A) Domestic Water Source:Municipal SystemPrivate Water CompanyShared Private WellIndividual Private WellHauled WaterNo WaterB) Approximate Property Size:Square FeetAcresC) Use of Property:Dwelling or Other ResidentialOther (describe):D) Occupancy/Use:Full TimeSeasonal/Part time: About % of yearIntermittentVacantUnknownIf dwelling, number of bedrooms:123456 or more.Number of on-site systems in use on this property?One (most common)Note: If more than one on-site system is in use on this property, aMore than one (indicate number): Report of Inspection form should be completed for each system.E) Estimated Design Flow:gallons per dayBasis for design flow (check either 1 or 2):1) Designated in permitting documents issued on or after January 1, 20012) Calculated or estimated based on (check one):For a dwelling, number of bedrooms times 150 gallons per day per bedroomFor a dwelling, fixture count as tabulated in A.A.C. R18-9-A314(4)(a)(i)If not a dwelling, summation of unit flows from Table 1, Unit Design Flows (AAC. R18-9-E323)Other (describe):F) Evaluation of actual flow versus the design flow indicated in E:Actual flow does not appear to exceed design flowActual flow may exceed design flow due to:Number of occupants (high occupancy)Bedroom count (actual number of bedrooms appears greater than number upon which original designmay have been based)Fixture countWater meter/usage recordsOther (describe):Unknown or could not be determinedG) Strength of sewage received by on-site wastewater treatment facility:Appears representative of typical residential sewage strengthIncludes waste from kitchen garbage disposal?YesNoUnknown or could not be determined.Appears to exceed strength of typical residential sewage becauseAppears to be weaker than typical residential sewage becauseUnknown or could not be determinedFORM GWS 432 (REVISED, FEBRUARY 16, 2007)DOWNLOAD THE LATEST UPDATE OF THIS FORM FROM THE ADEQ WEBSITE oad/inspection.docPAGE 2 of 7
REPORT OF INSPECTION7TAX PARCEL NO: DATE OF INSPECTION:GENERAL TREATMENT AND DISPOSAL WORKS INFORMATION (Complete either Section A or Section B)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 AA) System constructed or authorized forConstruction BEFORE January 1, 2001Conventional Septic Tank SystemSeptic TankDisposal TrenchDisposal BedDisposal by Chamber TechnologyDisposal by Seepage PitOther:Alternative Systems (check all that apply)Composting Toilet SystemPressure Distribution SystemGravelless TrenchNatural Seal Evapotranspiration BedLined Evapotranspiration BedWisconsin MoundEngineered Pad SystemIntermittent Sand FilterPeat FilterTextile FilterDenitrifying System Using Separated WastewaterStreams (e.g., RUCK )Sewage VaultAerobic SystemNitrate-Reactive Media FilterCap SystemConstructed WetlandSand-Lined TrenchDisinfection DevicesSurface DisposalSubsurface Drip Irrigation DisposalDesign flow is 3,000 gpd or moreOtherDate of Construction:Based on:Permitting documentationOther documentationEstimatedUnknown Construction DateSECTION BB) System authorized for construction ON ORAFTER January 1, 2001GP 4.02 Conventional Septic Tank/ Disposal SystemSeptic TankDisposal TrenchDisposal BedDisposal by Chamber TechnologyDisposal by Seepage PitAlternative Systems (check all that apply)GP 4.03 Composting Toilet SystemGP 4.04 Pressure Distribution SystemGP 4.05 Gravelless TrenchGP 4.06 Natural Seal Evapotranspiration BedGP 4.07 Lined Evapotranspiration BedGP 4.08 Wisconsin MoundGP 4.09 Engineered Pad SystemGP 4.10 Intermittent Sand FilterGP 4.11 Peat FilterGP 4.12 Textile FilterGP 4.13 Denitrifying System Using SeparatedWastewater StreamsGP 4.14 Sewage VaultGP 4.15 Aerobic SystemGP 4.16 Nitrate-Reactive Media FilterGP 4.17 Cap SystemGP 4.18 Constructed WetlandGP 4.19 Sand-Lined TrenchGP 4.20 Disinfection DeviceGP 4.21 Surface DisposalGP 4.22 Subsurface Drip Irrigation DisposalGP 4.23 Design flow from 3,000 to less than 24,000Gallons Per Day (4.23 GP)Date of Discharge Authorization for system(or Verification if issued from 1/1/2001 through 12/11/2005):C) Date of last inspection and/or pumping of septic tank:/ /UnknownD) Repairs or alterations to the facility since original installation?YesNoUnknownE) Is facility currently being serviced under a maintenance contract?YesNoUnknownFORM GWS 432 (REVISED, FEBRUARY 16, 2007)DOWNLOAD THE LATEST UPDATE OF THIS FORM FROM THE ADEQ WEBSITE oad/inspection.docPAGE 3 of 7
REPORT OF INSPECTION8TAX PARCEL NO: DATE OF INSPECTION:SEPTIC TANK INSPECTION AND PUMPING INFORMATION (for Conventional Septic Systems or AlternativeSystems that use a Septic Tank)A) Was the septic tank pumped as part of this inspection?YesNoIf No, septic tank was not pumped because:The septic tank was put into service less than 12 months before inspectionPumping or servicing was not necessary at the time of inspection based on manufacturer’s writtenoperation and maintenance instructions (applicable only to alternative technologies).No accumulation of floating or settled waste was present in the septic tank (may be applicable to certainremote or seasonal systems with little use).Additional Information:B) Septic tank material:Pre-cast concreteFiberglassPlasticOther:Could not be determinedC) Liquid level in septic tank before pumping:NormalBelow normalAbove normalCould not be determinedD) Access openings in septic tank:OneTwoThreeNoneOther (describe)E) Number of compartments in septic tank:OneTwoOther (describe)F) Depth of soil cover over tank access port or riser:inches orfeetG) Septic tank risers:PresentNot presentH) Capacity of septic tank:gallonsBased on:Measurements/dimensions of tankVolume PumpedEstimateCapacity could not be determinedI) Scum/Sludge (measured before pumping):i) Tank depth (air-liquid interface to bottom of tank:ftinchesii) Primary (upstream) chamber:Scum depth inches, Sludge depth inchesiii) Secondary (downstream) chamber: Scum depth inches, Sludge depth inchesJ) Baffle or sanitary “T” material:Pre-cast concreteFiberglassPlasticClayOther:K) Condition of baffles and sanitary “Ts”:i) Inlet baffle or “T”:FunctionalNot functionalNot presentNot determinedii) Outlet baffle or “T”:FunctionalNot functionalNot presentNot determinediii) Interior baffle:FunctionalNot functionalNot presentNot determinedL) Is there evidence of leakage into septic tank (infiltration)?YesNoCould not be determinedM) Is there evidence of leakage out of the septic tank (exfiltration)?YesNoCould not be determinedN) Is there evidence of :Root invasionCracks in tankDamaged lids or risersOther (describe):O) Is a sewer line cleanout present between building drain and septic tank?YesNoNot determinedP) Effluent filter:PresentNot presentCould not be determinedFilter serviced.Q) Repairs or other maintenance done to septic tank as part of this inspection?NoYes(describe at Item 12B)FORM GWS 432 (REVISED, FEBRUARY 16, 2007)DOWNLOAD THE LATEST UPDATE OF THIS FORM FROM THE ADEQ WEBSITE oad/inspection.docPAGE 4 of 7
REPORT OF INSPECTION9TAX PARCEL NO: DATE OF INSPECTION:DISPOSAL WORKS INSPECTION (All fields are required)A) Disposal is by:TrenchBedChamber TechnologySeepage PitNo. of pitsUnknownAlternative disposal works technology (provide further details in Item 10E)Unknown or could not be determinedB) Is there evidence of disposal works malfunction?NoYes (check all applicable conditions observed):Wet areasUnusual green/lush vegetationSewage smellLiquid discharges on surfaceDischarge pipes of unknown originImpaired hydraulic capacity (backups)Erosion encroachment, eroded/damaged containment berm or drainage control featureOther (describe):C) Any structural or drainage problems?:Localized surface settlingApparent root invasionAnimal damageOther (describe):NoYes (check all applicable conditions observed):D) Diversion valve or distribution box present?NoNot determinedYesIf yes: Type of component:Opened for inspection? ?YesNoOperational status?Functioning properlyNot functioning properlyCould not be determined (describe):E) Are inspection ports present in disposal works?NoYesi) If yes, number of functional ports:ii) If yes, indicate depth (in inches) from top of each port to:Port 1Port 2Not determinedPort 4Port 3Bottom of PortWastewater (liquid) surfaceF) Is a reserve disposal area available?YesNoUnknown or could not be determinedG) Repairs or other maintenance done to disposal works as part of this inspection?(describe in Item 12B)FORM GWS 432 (REVISED, FEBRUARY 16, 2007)DOWNLOAD THE LATEST UPDATE OF THIS FORM FROM THE ADEQ WEBSITE oad/inspection.docNoYesPAGE 5 of 7
REPORT OF INSPECTIONTAX PARCEL NO: DATE OF INSPECTION:10 ALTERNATIVE SYSTEMS INSPECTION (ADDENDUM– COMPONENTS AND APPURTENANCES)A) Are there wastewater-containing tanks or vessels other than a septic tank?NoYesIf yes, were tank(s) or vessel(s) pumped as part of this inspection?YesNo, because the tank or vessel was put into service less than 12 months before inspection.No, because pumping or servicing was not necessary at the time of inspection based on manufacturer’swritten operation and maintenance instructions.No, because no accumulation of floating or settled waste was present in tank(s) or vessel(s).B) Is there a pump or pumps?NoYes (number)Not determinedC) Are there system controls (switches, alarms, fluid level controls, etc.)?NoYesNot determinedi) If yes, system settings were:CheckedNot checkedAdjusted (describe):D) Are there other mechanical components or appurtenances?YesNoNot determinedi) If yes, describe mechanical components and appurtenances:E) Are there any disposal works components other than trench, bed, chamber technology, or seepage pit?NoNot determinedYes (describe):F) Describe any tests conducted, maintenance performed (other than pumping or adjustments of system controls), orrepairs completed to any of the treatment or disposal components or appurtenances addressed in this Section:G) Repairs or other maintenance done to components/appurtenances as part of this inspection?NoYes(describe in Item 12B)11 OTHER COMMENTS12 INSPECTION SUMMARY (Check All That Apply)A)Physical and operational condition of the on-site wastewater treatment facility, at time of inspection, appears to be:FunctionalB)Functional with concernsNot FunctionalRepairs were made as part of this inspection (describe):C) Repairs are recommended (describe):13 INSPECTOR’S CERTIFICATION (Required)I have inspected the physical and operational condition of the on-site wastewater treatment facility serving thisproperty on the date indicated below. I have completed this Report of Inspection to the best of my knowledge, andhave based the information contained in this form on observations and work performed at the time of inspection.However, this Report of Inspection does not imply nor guarantee any future performance of this facility in any way.Inspector’s SignatureDate of Inspection:NOTE TO BUYER:Within 15 calendar days after the date of property transfer, the Buyer shall submit a complete Notice of Transfer wnload/presale.doc) for the change of ownership, and file it with theapplicable agency indicated in the Notice of Transfer instructions. Information from this Report of Inspection form isneeded to fill out the Notice of Transfer that must be submitted by the Buyer.Effective February 2, 2007, you may be able to file your Notice of Transfer online. Go to the ADEQ web site enot.html for further information regarding this.FORM GWS 432 (REVISED, FEBRUARY 16, 2007)DOWNLOAD THE LATEST UPDATE OF THIS FORM FROM THE ADEQ WEBSITE oad/inspection.docPAGE 6 of 7
REPORT OF INSPECTIONTAX PARCEL NO: DATE OF INSPECTION:14 SKETCHES/PLANS/MAPS (Optional)FORM GWS 432 (REVISED, FEBRUARY 16, 2007)DOWNLOAD THE LATEST UPDATE OF THIS FORM FROM THE ADEQ WEBSITE oad/inspection.docPAGE 7 of 7
Report of Inspection. to Buyer with any other facility documentation in Seller’s possession Inspector completes . Report of Inspection. and gives to Seller . An inspector that is qualified under A.A.C. R18-9-A316, must complete the attached . Report of Inspection. form, and provide it to the seller as required by the Code.
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