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REPORTOFRESIDENTIALONSITEWATERSUPPLY&
SEWAGEDISPOSALINSPECTION
THISREPORTISSUBMITTEDASREQUIREDBYTHEWASHTENAWCOUNTYREGULATIONFORTHEINSPECTIONOF
RESIDENTIALONSITEWATERANDSEWAGEDISPOSALSYSTEMSATTIMEOFPROPERTYTRANSFERREGULATION
ThisformistobeonlycompletedbyinspectorscertifiedbytheWashtenawCountyEnvironmentalHealthDivision
(Rev.02/26/2013)

Date(s)Inspected:

OwnerName:

PropertyAddress:

TaxI.D.#:

Township:

ApplicantName:

State:

Zip:

Company(ifany):

StreetAddress:

City:

Cell#: (
)
Phone#:( )

EmailtoName:

at

FaxtoName:

at
(
)

System(s)Inspected:
OnsiteWaterSupply(Reasonnotinspected

OnsiteSewageDisposal(Reasonnotinspected

AgeofHome:
years
NumberofBedrooms:

CurrentNumberofResidents:

OR
TimeofVacancy:

NumberofBathrooms:

months

, being a Washtenaw County Certified Inspector, inspected the onsite

I,

watersupplyand/oronsitesewagedisposalsystemindicatedabove.Icertifythatthisinspectionwasdonewithin
the guidelines established by Washtenaw County and was completed in a thorough and complete manner.
Further,IcertifythatthisreportincludesallknowledgethatIhaveconcerningtheoperationandfunctionofsaid
system(s).

(Signature)
(Date)

CertificationNumber:

OfficeUseOnly:

Case#:TOS20
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WATERSUPPLYSYSTEM

AgeofWell:

Permit#:

ApprovalDate:

ft.

Verifiedfrom:WellLogDrillerCountyRecordsOwner

Numberofotherwellsonproperty:

WellDepth:

Location:

Onproperty

Completeforeachadditionalwell:
Offproperty

Use:

Sharedwell?YesNoDiameter:
inches
Flowingwell?YesNo
Inuseandproduceswater?YesNo
Flowdischargedproperly?YesNo

Separatefrompotablewatersupply?YesNo

IsolationDistancesNotMet:(fillinactualdistanceifminimumnotmet)

Drainfield(<100ft.)
Septictank(<50ft.)
Grinderpump(<50ft.)
Sewerline(<50ft.)
HazMatstorage(<100ft.)
Fueloiltank(<100ft.)

PumpType:

ft.
ft.
ft.
ft.
ft.
ft.Buried?YesNoInbasement?YesNoConcretefloor?YesNo

Cycling:

Submersible
Long(>90sec.)
DeepWellJet* Adequate(3090sec.)

ShallowWellJet*
Short(<30sec.)
Other:

*
*ProtectedSuctionLine?YesNo

Yield(approx.): gpm
CasingDiameter:inches

Termination:

WellCap:

Abovegrade(inchesaboveground)
Basementoffset(inchesabovefloor)
DrainedPit( inchesabovefloor)
UndrainedPit
DugWell

NotFound/Buried

Structurallysound
Caploose
Capmissing
Caploosew/insects
Cap/conduit/casingdamaged

Venting:

Notvented
Screenedvent
Unscreenedvent
Unscreenedventw/insects

WaterTreatmentInUse:

Softener
SedimentFilter
IronRemoval
ReverseOsmosis*PointofuseWholehouse
Other:

*Initialwatersamplesmustbetakenfromuntreatedwater.AdditionalArsenicsampleshouldbetakenfromtreatmentdevice.
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SEWAGEDISPOSALSYSTEM

Permit#:

Location:

ApprovalDate:

Municipal/SanitarySewerAvailable:YesNo

Onproperty
Offproperty

NotConnectedtoSystem:

Toilet(s)
Sink(s)
Shower(s)
Tub(s)
Laundry
Other:

ConnectedtoSystem:

Footingdrains
Watertreatmentdischarge(s)
HVACdischarge(s)
Stormwaterdrain(s)
Other:

SEPTICTANK(S):IfseptictankshavenotbeenpreviouslyinspectedandapprovedbythisDepartment,aSepticTank
MaintenanceReportfromaLicensedSewagePumpermustbeattached.

NumberofTanks:

Lastpumped:

Totalcapacity: gal.Verifiedby:CountyRecordsPumpingReceipts
Accessibleforpumping:YesNo

yearsago

PumpAlarmFunctional:YesNo
Tankaccesswithin18ofgrade:YesNo

*IfNo,pleaseexplain:

IsolationDistancesNotMet:(fillinactualdistanceifminimumnotmet)

Surfacewater(<25ft.)

ft.

Nearestwell(<50ft.)

ft.

DISPOSALAREA(S):
Number:

Type:

Nonefound
One
Multiple/oneconnected
Multipleconnected*
Multiplew/diverter*

Bedconventional
Beddeepexcavation
Bedraised
Modifiedfill

Sizeofbed:

sq.ft.( ft.X

ft.)

Verifiedby:

Countyrecords
Fieldmeasurement

Trenches

NumberofTrenches:

Trenchwidth: ft.Trenchlength:

Drywell
Other:

*Note:IfmultiplefieldsareconnectedpleaseincludeadditionalPage4foreachfieldandshowonsiteplan.
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ft.

DRAINFIELDCONDITION:Showlocationandconditionofeachtestholeonsiteplan.
Sewageexposed(includingbackup,directdischarge,surfacing,etc.):YesNo

inches

Depthofcover: inchesto
(minimum)
(maximum)

Saturationoffield:

Sludge/Biomatinfield:

None
<50%belowtileholes
>50%belowtileholes
<50%abovetileholes
>50%abovetileholes

Encroachmentonfield:YesNo

(IfYes,showtypeandlocationonsiteplan.)

None
<50%belowtileholes
>50%belowtileholes
<50%abovetileholes
>50%abovetileholes

IsolationDistancesNotMet:(fillinactualdistanceifminimumnotmet)

Nearestwell(<100ft.):
Surfacewater(<50ft.):

Tile:

Plasticperrecords/age
Plasticperowner
Concrete/clayperrecords/age
Concrete/clayperowner
Concrete/clayobserved

(Approx.%blockage________)

ft.
ft.

Sandysoilunderfield:YesNo

Woodyvegetationon/within5ftofsystem:YesNo

Surfacewaterdivertedfromsystem:YesNo
Automaticsprinklerson/nearsystem:YesNo

INSPECTOROBSERVATIONS/COMMENTS/RECOMMENDATIONS

Based on data presented in this inspection report, the Washtenaw County Environmental Health Division will issue a letter
stating whether the water supply and/or sewage disposal system meets minimum standards for sale of the property. The
following observations or recommendations for extending the life of these systems are in addition to any requirements
addressedbytheEnvironmentalHealthDivision:

ATTACHREQUIREDWATERSAMPLES(COLIFORMBACTERIA,NITRATES,ANDARSENIC)
ANDSITEPLAN*TOREPORT
(*Siteplansmustcontainlocationandconditionsofeachtestholeandanytileexcavation.)

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