Fillable Time Of Transfer Inspection Report Dnr Form 542 0191 - Time of Transfer Inspection Worksheet

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Time Of Transfer Inspection Report Dnr Form 542 0191 - Time of Transfer Inspection Worksheet

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10-2008 542-0191
Time of Transfer Inspection Report (DNR Form 542-0191)
Property information
Current Owner _______________________________________________________________________
Buyer ____________________________________ Realtor ___________________________________
Mailing Address ______________________________________________________________________
Site Address/County __________________________________________________________________
No. of Bedrooms ____ Last Occupied? ______ Disposal? Y / N Softener? Y / N H
2
O Supply? ____
Records Available ______ Permit/Installation Date ____________ Installer ______________________
Septic System Information
Septic Tank(s): Size ________________ Material ________________ Condition ________________
Tank Pumped? ______________ Date ______________ Licensed Pumper _____________________
Septic/Trash/Processing Tank: Size ___________ Material ____________ Condition _____________
Tank pumped? _____________ Date _______________ Licensed Pumper _____________________
Aerobic treatment unit (ATU) MFGR ____________________________ Size __________________
Tank Pumped? ____________ Date _______________ Licensed Pumper _____________________
Maintenance Contract? ________ Expiration Date ____________ Service Provider ______________
Condition ___________________________________________________________________________
Pump Ttanks/Vaults: Type ______________ Size _______________ Condition __________________
Distribution System: Distribution Box _________ Outlets Used __________ Condition ___________
Header Pipe(s) _____________ Number of Lines _________________
Pressure Dosed? ____________
Secondary Treatment
Length of Absorption Fields _____________________ Determined by __________________________
Condition of Fields ____________________________ Determined by __________________________
Type of Trench Material _______________________
Size of Sand Filter _____________________________ Determined by __________________________
Vent Pipes Above Grade? _______________________ Discharge Pipe Located? __________________
Effluent Sample Taken? ________________________ Results ________________________________
Media Filters: Type ___________________________
Maintenance Contract? _________ Expiration Date _____________ Service Provider _____________
Condition ___________________________________________________________________________
NPDES General Permit No. 4: Required? ________ Permitted? __________ NOI submitted ________
10-2008 542-0191
Time of Transfer Inspection Worksheet
Other Components
Alarms __________ Working? ___________ Disinfection ___________ Working? __________
Control Box ___________ Timers__________ Inspection Ports __________
Other Components ____________________________________________________________________
____________________________________________________________________________________
Overall condition of the private sewage disposal system
Acceptable? ____________________ Unacceptable? ______________________
Explain (attach additional pages as needed): ________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Comments: __________________________________________________________________________
____________________________________________________________________________________
Site status at conclusion of Time of Transfer inspection:
Verify that controls are set on the appropriate mode.
Power is on to all components.
Revisit all components to verify lids are secure.
Gather all tools for removal from the site.
Verify that no sewage is on the ground surface.
Using this worksheet, write a narrative report of the inspection results.
Submit a copy of this report, including your narrative, to the city/county environmental health office, the
DNR and the county Recorder in the county where the inspection was conducted.
This report indicates the condition of the private sewage disposal system at the time of the inspection. It
does not guarantee that it will continue to function satisfactorily.
Signature of Certified Inspector: __________________________________ Date: _________________
Name (print): ______________________________________________ Certficate #: _____________
Address: ____________________________________________________________________________
Phone # _______________________________
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Time Of Transfer Inspection Report Dnr Form 542 0191 - Time of Transfer Inspection Worksheet

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Completed 28 June 2020

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