DRAFT

Building Sanitary Sewer Inspection Form 1A

Sanitary Sewer OverflowsThis form must be completed and signed by a licensed contractor who is on the City of Santa Cruz Public Works Department list of “Certified Sewer Inspectors” and submitted to:

City of Santa Cruz Public Works Department 809 Center Street, Room 201 Santa Cruz, CA 95060 831-420-5160

Property Information:Property Address: _________________________________________________________________________

Property Owner(s) name: __________________________________________________________________pResidential, number of units served_______ pCommercial Mailing address of owner (if different from above): ______________________________________________

City: _______________________________________ State: _________ Zip Code: __________________

Owner Contact Phone Number: _____________________________________________________________

Inspector Information:Company Name:___________________________Inspector Name: _________________________________Address: ____________________________________Contact Phone: _______________________________email address (print) ______________________________________________________________________ Inspector Pipeline Assessment Certification (PACP) NASSCO #: ______________________________________________

Inspection: Date of Inspection:____/____/_____ Pipe Size: ______________ Pipe Material: ________________________

CCTV Date:____/____/_____ Time:________ Camera Direction: pWith Flow pAgainst Flow Length: ______

Cause of Overflow: pRoots pGrease pOther _______________________________________________

Please answer ALL of the questions below:Yes____ No____ There is a standard clean-out in the sidewalk areaYes____ No____ (If NO to above) clean-out is accessible outside of buildingYes____ No____ There is a sewer lift station (pump) at this propertyYes____ No____ Property has been verified as not requiring a backwater valveYes____ No____ Property has been verified as having a working backwater valveYes____ No____ Property needs a backwater valveYes____ No____ Property has been verified as having no outside drains or sump pumps connected to the building sanitary sewer.

Cause of Overflow: Yes____ No____ Roots, Correction Made: ______________________________________________________Yes____ No____ Faulty Clean Out, Correction Made: _____________________________________________Yes____ No____ Offset Joint, Correction Made: _________________________________________________Yes____ No____ Grease, Correction Made: _____________________________________________________Yes____ No____ Structural, Correction Made: ___________________________________________________

Other (not listed): _______________________________________________________________________

Please give your professional opinion on the condition of the building sanitary sewer or sanitary sewer collection system: _______________________________________________________________________________________________________________________________________________________________

NOTE: 1. No Building Sanitary Sewer shall have a grade (4) or grade (5) structural condition. 2. No Building Sanitary Sewer shall have a grade (3) operational condition. (When the inspection camera is submerged at any time during video inspection then the sewer is determined to have a grade three (3) operational Sag.)

As the inspector for the above-mentioned property, I certify that I have read the requirements for building sanitary sewer or sanitary sewer collection system in City of Santa Cruz Municipal Code 16.08. I certify under penalty of law that the information and video recording I have provided with this form is true and correct.

Signature of Inspector:___________________________________________ Date: ___________________

Structural Defect Groups include: Cracks, breaks, openings, rodent holes, structural sags or missing portions. Structural Observation Codes: l Grade 5, Collapse or collapse imminent. l Grade 4, Collapse likely in foreseeable future l Grade 3, Collapse unlikely in near future l Grade 2, Minimal collapse risk l Grade 1, Acceptable structural condition

For City Use Only

Date Received: ________________________________Reviewed by: __________________________________

pA review of the video file revealed that a replacement of repairs to the building sanitary sewer is NOT necessary.

pA review of the video file revealed that a repair to the building sanitary sewer is required.

pA review of the video file revealed that the sewer line is required to be replaced.

l Example of Structural Grade 5:

City of Santa Cruz Building Sanitary Sewer Inspection Form - Sanitary Sewer OverflowsImmediately: if a property has a sanitary sewer overflow it shall be considered a nuisance and the property owner or homeowner association shall immediately (upon becoming aware) begin taking actions to eliminate the overflow. Evidence of a remedy to be submitted: Within 14 calendar days after the notice of violation is served. All sanitary sewer overflow remedies shall show a building sanitary sewer with no pipe structural condition grade 4 or 5 and/or no grade 3 operational defects.

Operational Defect Groups include: Roots, grease deposits, other solids, which may impede the flow or obstruct the transmission of wastewater.Operational Observation Codes: l Grade 3, l Grade 2, l Grade 1

l Example of Structural Grade 3:

l Example of Operational Grade 3:

l Example of Operational Grade 2:l Example of Structural Grade 4:

STRUCTURAL OPERATIONAL

Severe cracking with offset collapse:Distance:_______ Note: ____________________________Distance:_______ Note: ____________________________Distance:_______ Note: ____________________________

Multiple structural cracks:Distance:_______ Note: ____________________________Distance:_______ Note: ____________________________Distance:_______ Note: ____________________________

Multiple hairline cracks.Distance:_______ Note: ___________________________

Major root intrusion:Distance:_______ Note: ____________________________Distance:_______ Note: ____________________________Distance:_______ Note: ____________________________

Medium root intrusion:Distance:_______ Note: ____________________________Distance:_______ Note: ____________________________Distance:_______ Note: ____________________________

DRAFT

Building Sanitary Sewer Inspection Form 2BPrior to a transfer of ownership by sale of any property or building. This form must be completed and signed by a licensed contractor who is on the City of Santa Cruz Public Works Department list of “Certified Sewer Inspectors” and submitted to:

City of Santa Cruz Public Works Department 809 Center Street, Room 201 Santa Cruz, CA 95060

Property Information:Property Address: _________________________________________________________________________

Property Owner(s) or Representative name: ___________________________________________________pResidential pCommercial Mailing address of owner (if different from above): ______________________________________________

City: _______________________________________ State: _________ Zip Code: __________________

Owner Contact Phone Number: _____________________________________________________________

Inspector Information:Company Name:___________________________Inspector Name: _________________________________

Address: ____________________________________Contact Phone: _______________________________

email address (print) ______________________________________________________________________ Inspector Pipeline Assessment Certification (PACP) NASSCO #: ______________________________________________

Inspection: Date of Inspection:____/____/_____ Pipe Size: ______________ Pipe Material: ________________________

Please answer ALL of the questions below:Yes____ No____ Inspection is for the construction of a new dwelling unit that utilizes existing property sewerYes____ No____ There is a standard clean-out in the sidewalk areaYes____ No____ (If NO to above) clean-out is accessible outside of buildingYes____ No____ There is a sewer lift station (pump) at this propertyYes____ No____ Inspection could NOT be done due to substandard clean-outYes____ No____ Property has been verified as not requiring a backwater valveYes____ No____ Property has been verified as having a working backwater valveYes____ No____ Property needs a backwater valveYes____ No____ Property has been verified as having no outside drains or sump pumps connected to the sewer systemYes____ No____ Property has a building sanitary sewer that was constructed within 10 yearsYes____ No____ Property sewer was completely replaced within 10 years

Yes____ No____ Property sewer has been determined to have a structural grade 5 condition, (inspector shall provide video of sewer to buyer prior to correcting grade 5 condition)

CCTV Date:____/____/_____ Time:________ Camera Direction: pWith Flow pAgainst Flow Length: _____________________________________

Describe structural grade 5 condition and submit post DVD, flash drive, or digital video of remedy to the City of Santa Cruz Public Works Department: ______________________________________________________________________________________________________________________________________________________________________________

NOTE: 1. No Building Sanitary Sewer shall have a grade (5) structural condition. 2. No Building Sanitary Sewer shall have a grade (3) operational condition. (When the inspection camera is submerged at any time during video inspection then the sewer is determined to have a grade three (3) operational Sag.)

As the inspector for the above-mentioned property, I certify that I have read the requirements for building sanitary sewer or sanitary sewer collection system in City of Santa Cruz Municipal Code 16.08. I certify that the information and video recording I have provided with this form is true and correct.Signature of Inspector:___________________________________________ Date: _____________________________________

Structural Defect Groups include: Cracks, breaks, openings, rodent holes, structural sags or missing portions. Structural Observation Codes: l Grade 5, Collapse or collapse imminent. l Grade 4, Collapse likely in foreseeable future l Grade 3, Collapse unlikely in near future l Grade 2, Minimal collapse risk l Grade 1, Acceptable structural condition

For City Use Only

Date Received: ________________________________Reviewed by: __________________________________

pA review of the video file revealed that a replacement of repairs to the building sanitary sewer is NOT necessary.

pA review of the video file revealed that a repair to the building sanitary sewer is required.

pA review of the video file revealed that the sewer line is required to be replaced.

l Example of Structural Grade 5:

City of Santa Cruz Building Sanitary Sewer Inspection FormUpon Transfer of Title of Real Property or Construction of a New Dwelling Unit or

New Dwelling Unit Utilizing an Existing Building Sanitary Sewer or Commercial BuildingAll existing residential and commercial property building sanitary sewers shall, prior to the transfer of title whenever any property is to be transferred to or vested in any other person or entity, except for an interspousal transfer as defined in the Revenue and Taxation Code Section 63, shall be inspected by a NASSCO – PCLP certified inspector.

Operational Defect Groups include: Roots, grease deposits, other solids, which may impede the flow or obstruct the transmission of wastewater.Operational Observation Codes: l Grade 3, Severe root intrusion (50% or more) or Sag in pipe: camera is completely submerged. l Grade 2, Moderate root intrusion (50% or less) or camera is partially submerged. l Grade 1

l Example of Structural Grade 3:

l Example of Operational Grade 3:

l Example of Operational Grade 2:l Example of Structural Grade 4:

STRUCTURAL OPERATIONAL

Severe cracking with offset collapse:Distance:_______ Note: ____________________________Distance:_______ Note: ____________________________Distance:_______ Note: ____________________________

Multiple structural cracks:Distance:_______ Note: ____________________________Distance:_______ Note: ____________________________Distance:_______ Note: ____________________________

Multiple hairline cracks.Distance:_______ Note: ___________________________

Major root intrusion:Distance:_______ Note: ____________________________Distance:_______ Note: ____________________________Distance:_______ Note: ____________________________

Medium root intrusion:Distance:_______ Note: ____________________________Distance:_______ Note: ____________________________Distance:_______ Note: ____________________________

DRAFT

Building Sanitary Sewer Inspection Form 3C

Cleaning of Collection Systems Be cleaned a minimum of once every two (2) years if the system collects __ wastewater from ten or more building sanitary sewers or every five years if less than 10 building sanitary sewers .

This form must be completed and signed by a licensed contractor who is on the City of Santa Cruz Public Works Department list of “Certified Sewer Inspectors” and submitted to:

City of Santa Cruz Public Works Department809 Center Street, Room 201Santa Cruz, CA 95060 831-420-5160

Property Information:Property Address: _________________________________________________________________________

Property Owner(s) or Representative name: ___________________________________________________pNumber of units:________ Mailing address of owner (if different from above): ______________________________________________

City: _______________________________________ State: _________ Zip Code: __________________

Owner Contact Phone Number: _____________________________________________________________

Property Manager Phone Number: ___________________________________________________________

Email Address:________________________________ Date of Construction: _________________________

Inspector Information:Company Name:___________________________Inspector Name: _________________________________

Address: ____________________________________Contact Phone: _______________________________

email address (print) ______________________________________________________________________ Inspector Pipeline Assessment Certification (PACP) NASSCO #: ______________________________________________

Cleaning: Date of Cleaning:____/____/_____ Pipe Size: ______________ Pipe Material: _________________________

Method of Cleaning: pHydro pMechanical Number of Manholes ___________________________

Lineal Feet of cleaning done: __________________________________________________________________

Please answer ALL of the questions below:Yes____ No____ There is a sewer lift station (pump) at this propertyYes____ No____ Property has been verified as having no outside drains or sump pumps connected to the sewer systemYes____ No____ Roots visible in the manhole(s)

Other Comments: ________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

NOTE: 1. No Sanitary Sewer Collection System shall have a grade (5) structural condition. 2. No Sanitary Sewer Collection System shall have a grade (3) operational condition. (When the inspection camera is submerged at any time during video inspection then the sewer is determined to have a grade three (3) operational Sag.)

As a contractor for the above-mentioned property, I certify that I have read the requirements for building sanitary sewer or sanitary sewer collection system in City of Santa Cruz Municipal Code 16.08. I certify under penalty of law that the information and video recording I have provided with this form is true and correct.

Signature of Inspector:___________________________________________ Date: ___________________________

DRAFT

Building Sanitary Sewer Inspection Form 4D

Inspection of Collection Systems Every 10 YearsPrivate sanitary sewer collection systems shall be required to televise the sanitary sewer pipes every ten (10) years.

This form must be completed and signed by a licensed contractor who is on the City of Santa Cruz Public Works Department list of “Certified Sewer Inspectors” and submitted to:

City of Santa Cruz Public Works Department 809 Center Street, Room 201 Santa Cruz, CA 95060 831-420-5160

Property Information:Property Address: _________________________________________________________________________

Property Owner(s) or Representative name: ___________________________________________________pNumber of units:________ Mailing address of owner (if different from above): ______________________________________________

City: _______________________________________ State: _________ Zip Code: __________________

Owner Contact Phone Number: _____________________________________________________________

Property Manager Phone Number: ___________________________________________________________

Email Address:________________________________ Date of Construction: _________________________

Inspector Information:Company Name:___________________________Inspector Name: _________________________________

Address: ____________________________________Contact Phone: _______________________________

email address (print) ______________________________________________________________________ Inspector Pipeline Assessment Certification (PACP) NASSCO #: ______________________________________________

Inspection:Date of Inspection:____/____/____ Pipe Size: _______

Pipe Material:__________________________________ Number of Manholes __________________________

Lineal Feet of televise done: __________________________________________________________________

Please answer ALL of the questions below:

Yes____ No____ There is a sewer lift station (pump) at this propertyYes____ No____ Property has been verified as having no outside drains or sump pumps connected to the sewer systemYes____ No____ Roots visible in manhole(s)

Yes____ No____ Property sewer has been determined to have a structural grade 5 condition, (inspector shall provide video of sewer to owner prior to correcting grade 5 condition)

Post CCTV Date:____/____/_____ Time:________ Camera Direction: pWith Flow pAgainst Flow Length: _________________________

Describe structural grade 5 condition and submit POST DVD, flash drive, or color digital video of remedy to the City of Santa Cruz Public Works Department:

_______________________________________________________________________________________

_______________________________________________________________________________________

NOTE: 1. No Sanitary Sewer Collection System shall have a grade (5) structural condition. 2. No Sanitary Sewer Collection System shall have a grade (3) operational condition. (When the inspection camera is submerged at any time during video inspection then the sewer is determined to have a grade three (3) operational Sag.)

As an inspector for the above-mentioned property, I certify that I have read the requirements for building sanitary sewer or sanitary sewer collection system in City of Santa Cruz Municipal Code 16.08. I certify under penalty of law that the information and video recording I have provided with this form is true and correct.

Signature of Contractor:___________________________________________ Date: __________________________

Structural Defect Groups include: Cracks, breaks, openings, rodent holes, structural sags or missing portions. Structural Observation Codes: l Grade 5, Collapse or collapse imminent. l Grade 4, Collapse likely in foreseeable future l Grade 3, Collapse unlikely in near future l Grade 2, Minimal collapse risk l Grade 1, Acceptable structural condition

For City Use Only

Date Received: ________________________________Reviewed by: __________________________________

pA review of the video file revealed that a replacement of repairs to the building sanitary sewer is NOT necessary.

pA review of the video file revealed that a repair to the building sanitary sewer is required.

pA review of the video file revealed that the sewer line is required to be replaced.

l Example of Structural Grade 5:

City of Santa Cruz Building Sanitary Sewer Inspection FormMaintenance Agreement Form for Sanitary Sewer Collection Systems

Private sanitary sewer collection systems that serve five (5) dwelling units or more shall be required to televise those same sanitary sewer pipes every ten (10) years.

Operational Defect Groups include: Roots, grease deposits, other solids, which may impede the flow or obstruct the transmission of wastewater.Operational Observation Codes: l Grade 3, Severe root intrusion (50% or more) or Sag in pipe: camera is completely submerged. l Grade 2, Moderate root intrusion (50% or less) or camera is partially submerged. l Grade 1

l Example of Structural Grade 3:

l Example of Operational Grade 3:

l Example of Operational Grade 2:l Example of Structural Grade 4:

STRUCTURAL OPERATIONAL

Severe cracking with offset collapse:Distance:_______ Note: ____________________________Distance:_______ Note: ____________________________Distance:_______ Note: ____________________________

Multiple structural cracks:Distance:_______ Note: ____________________________Distance:_______ Note: ____________________________Distance:_______ Note: ____________________________

Multiple hairline cracks.Distance:_______ Note: ___________________________

Major root intrusion:Distance:_______ Note: ____________________________Distance:_______ Note: ____________________________Distance:_______ Note: ____________________________

Medium root intrusion:Distance:_______ Note: ____________________________Distance:_______ Note: ____________________________Distance:_______ Note: ____________________________

DRAFTBuilding Sanitary Sewer Inspection Form 5E

Annual Inspection of Lift StationsSanitary Sewer Lift Stations and Ejector Pumps from sanitary sewer collection systems with five units or more shall be inspected annually and less than five units inspected every five years. This form must be completed and signed by a licensed contractor who is on the City of Santa Cruz Public Works Depart-ment list of “Certified Sewer Inspectors” and submitted to:

City of Santa Cruz Public Works Department 809 Center Street, Room 201 Santa Cruz, CA 95060 831-420-5160

Property Information:Property Address: _________________________________________________________________________

Property Owner(s) or Representative name: ___________________________________________________pResidential pCommercial Mailing address of owner (if different from above): ______________________________________________

City: _______________________________________ State: _________ Zip Code: __________________

Owner Contact Phone Number: _____________________________________________________________

Property Manager Phone Number: ___________________________________________________________

Email Address:________________________________ Date of Construction: _________________________Inspector Information:

Company Name:___________________________Inspector Name: _________________________________

Address: ____________________________________Contact Phone: _______________________________

email address (print) ______________________________________________________________________ Inspector Pipeline Assessment Certification (PACP) NASSCO #: ______________________________________________

Inspection of Sewage Ejector Pumps for Single Family Dwellings: Date of Inspection:____/____/_____ Please answer ALL of the questions below:

Yes____ No____ The tank and pump is accessible for inspection, pump replacement, or repairsYes____ No____ There is adequate tank ventingYes____ No____ There is no evidence of leaks, exposed wires, unprotected openings into the tankYes____ No____ There is no evidence of backups or overflows which may show recent failuresYes____ No____ The pump is operating properly, (turn on a nearby plumbing fixture to fill the reservoir tank, observe the pump operation, turning on and off normally)Yes____ No____ The sewage ejector system has a working alarm that has been tested and will sound upon high water level or pump failureYes____ No____ The ejector/grinder- pump reservoir or basin is undamaged, (the fiberglass or plastic container is intact, with no cracks, breaks, improper holes, or other damage) Yes____ No____ The lid fits securely, is proper material, and not be leakingYes____ No____ A check valve is properly installed and functioning on the discharge line

Inspection of Sewage Lift Station: Date of Inspection:____/____/_____

Yes____ No____ All pumps are operating properly, (run each pump for a short time)Yes____ No____ Wet well have been cleaned and is free of grease and debris, control floats are clean, piping is in good conditionYes____ No____ Floats have been turned on and off and work properlyYes____ No____ High water float and alarm is working properlyYes____ No____ All lift station valves have been exercised and are working properly (including check valves)Yes____ No____ If applicable, run time for each pump has been recordedYes____ No____ If applicable, generator has been tested and transfers properly

As a contractor for the above-mentioned property, I certify that I have read the requirements for building sanitary sewer or sanitary sewer collection system in City of Santa Cruz Municipal Code 16.08. In order to pass inspection all questions specific to type of installation must be answered YES and ALL deficiencies must be corrected. I certify under penalty of law that the information and video recording I have provided with this form is true and correct.

Signature of Inspector:___________________________________________ Date: _____________________________________