4106 Nicols Rd - Inspection FormResidential Sanitary Sewer Service
Compliance Inspection
Date ij 1 /f 1 "0
e4 ,`'� / / / Diisk#
Name �rft/��
PlD Number
House Number
Alternative Mailing Address
'4/227 %
Owner /Occupant Signature
Compliance
O No foundation drain connection
Id No roof drain connection
O Sump pit not connected to
sanitary sewer
O Sump pump properly piped
J® No sump pump
Service Lateral Inspection Findings
Roots / " 7
Poor Pipe joints
Time
Street Name
For information call 651A70.2788
Mineral Deposits_
Sag /Pipe Deflection B
Damaged Pipe_
Transition 1 /1Aii.1... , /( rr- /4
4" to b "Transition:
Sump pumps
Foundation drains
Roof drains
f r
r
i
White Copy: Property Owner
Total
4
Correctly
am
O pm
W-Li2J
(C)c-'
%
Non - Compliance
Clear water conn ctions to
sanitary sewer fr
O Service lateral defects
O Defective manholes
O Sump pump connected to sanitary
sewer
O Flexible sump pump piping
Number of stacks
Length of Service:
Number. Discharged
Incorrectly
Unknown
Record Number
Pit' \ne
f
Time
yam
O pm
//
f ✓ linpe r Signature
Obstruction
Unable to push past
feet
Entered S:L.at
No Access
O No one in
O Access to service .
lateral needed
O inspection
refused
Final Cleanout:
Notes % . „. �f
VIVV.A.1 a � � r� � � _ /) ,
Yellow Copy: City of fagan Pink Copy: SEH