Authorization No.
System No.
Date Final Rec’d
Edoctus System ID
ENVIRONMENTAL COMPLAINTS AND LOCAL SERVICES DIVISION
ON-SITE SEWAGE TREATMENT SYSTEM INSPECTION REPORT
PLEASE PRINT LEGIBLY OR TYPE
I. PROPERTY INFORMATION:
Name / Mailing Address of Owner:
First Name
Last Name
Address
City
State
Zip Code
Owner’s E-Mail Address (Optional):
OK
Property Address:
Street Address
City
State
Zip Code
County
Legal Description:
¼ and ½ ‘s
Section
Township
Range
Lot
Block
No
Type:
Subdivision
Finding Location:
(Blocks or miles from a given point)
II. GENERAL INFORMATION:
TYPE OF WORK:
New Installation
TYPE OF SYSTEM:
DESIGN FLOW:
Conv Subsurface
Individual w /
Modification
Repair
ALTERNATIVE SYSTEM:
Low Pressure Dosing
bedrooms
Shallow Ext
Lagoon
Yes
ET/A
CLASSIFIED AS CLASS V INJECTION WELL:
First Name
Soil Group
Aerobic w/Nitrogen Reduction Mfg
gal/day – Type:
Small Public System
REPORT FOR ON-SITE SEWAGE COMPLETED BY:
SOIL TEST RESULTS:
Aerobic
Yes
No
Last Name
Percolation Rate
min/in
DATE CONDUCTED:
Design Only Date:
III. SYSTEM COMPONENTS:
NOTES
Complete all relevant information for each component installed, modified or repaired.
LIFT STATION
Tank:
Plastic/Fiberglass
Concrete
Liquid capacity:
gallons
TRASH TANK / SEPTIC TANK
Tank:
Plastic/Fiberglass
Concrete
Liquid capacity:
gallons
AEROBIC TREATMENT UNIT
ATU:
Plastic/Fiberglass
Concrete
Capacity rating:
gpd
FLOW EQUALIZATION TANK
Tank:
Plastic/Fiberglass
Concrete
Liquid capacity:
gallons
Dosing rate:
gph
LOW PRESSURE DOSING TANK
Tank:
Plastic/Fiberglass
Concrete
Liquid capacity:
gallons
Dosing rate:
gph
DISINFECTION
ATU PUMP TANK
Method of Disinfection Used:
Tank:
Plastic/Fiberglass
Liquid Chlorinator
Concrete
Drip - Total length of line:
IRRIGATION
Retention structures used:
Yes
Liquid capacity:
feet.
No
ANSI/NSF 46
gallons
ft2.
Spray -Total irrigation area:
Total trench length:
feet
Trench depth:
inches
Media depth:
inches
ABSORPTION TRENCHES
Media used:
LAGOON
Rock
Chambers
Bottom dimensions:
Polystyrene
Other:
feet x
feet
IV. INSTALLER INFORMATION:
Name:
Date Work Completed:
First Name
Is Installer Certified:
Yes
No
Last Name
Mailing Address:
Phone #:
Address
City
State
Zip Code
V. CERTIFIED INSTALLER USE ONLY:
I hereby certify that I installed / modified / repaired the above-described on-site sewage treatment system in compliance with OAC 252:641.
Installer’s Signature
Installer’s Certification #
Date Signed
VI. DEQ USE ONLY:
DEQ REVIEWED CERTIFIED INSTALLER’S FINAL INSPECTION
SYSTEM INSPECTED BY DEQ ON (Date):
DEQ Final Inspection
Joint Inspection
This system COMPLIES with OAC 252:641
This system FAILS to comply with OAC 252:641
Environmental Specialist’s Signature
Revised 8/1/2014
OR
DATE FILED:
Notes:
Employee ID
DATE REJECTED:
ES Initials:
Date Paperwork Signed and Issued
DEQ Form 641-576A/S
System No.
Owner’s Last Name
VII. SEPARATION DISTANCES:
Record all applicable separation distances in feet.
Trash Tank/
Septic Tank
Flow
Equalization
Tank
Lift
Station
ATU
Pump
Tank
Solid
Pipe
Perforated
Pipe /
Chambers
Sprinkler
Heads
Sprinkler
Spray
N/A
N/A
N/A
N/A
N/A
N/A
Drip
Irrigation
Lines
Lagoon
Private Water Supply:
Public Water Supply:
Buildings:
Other Structures:
N/A
N/A
N/A
N/A
N/A
Waterline:
N/A
N/A
Property Line:
Impoundment/Stream:
N/A
French Drain:
N/A
VIII. LAYOUT OF SYSTEM:
Sketch a detailed drawing of the system installation/ modification in the box below
making sure to differentiate between existing components and new or modified ones.
SKETCH
N
REMARKS:
or
Septic Tank
Revised 8/1/2014
Distribution
Box
Retention
Structure
T
L
†
O
Tee
Ell
Cross
Water Well
Absorption Line
or Drip Line
DEQ Form 641-576A/S