Sanitary Survey - Blank Forms (Version 23)

                              (Generated on 03/03/23)

General Questions

General Questions

Yes No N/A Unk
1. Have material modifications been made to the PWS since the last survey?
2. If yes, were plans and specs submitted to and approved by DEQ?
3. Were samples taken during the survey by the inspector? (If yes, indicate what samples were collected in the Notes.)

Wells

Well Questions

Yes No N/A Unk
1. Is there a well log for the source?    EDMS#:     
2. Are surrounding land uses creating health hazards or increasing the potential for source contamination? (Setbacks not met, dumping, etc.)
3. Are toxic or hazardous chemicals stored on the well lot? (pesticides, paint, herbicides, fertilizers, petroleum, etc.)
4. Are pesticides, herbicides, or fertilizers applied to the well lot without approval?
5. If the well is in a pit, is the pit protected from flooding and contamination? (watertight walls and floor, floor drain, acceptable pit cover, etc.)
6. Is the well (not located in a pump house) protected from unauthorized access? (Locking cap, fenced, etc.) (Recommended)
7. Is the well protected from flooding? (casing height >highest flood level, >18" outdoor, >12" indoor, etc.)
8. Is the well properly vented? (24 mesh screen, open downward >18" outdoor or >12" indoor, etc.)
9. Does the well casing and cap prevent contamination and surface water entry?
10. Is a raw water smooth nosed sample tap provided on the discharge pipe? (Prior to any treatment)
11. Is a working flow meter provided? (Instant, totaling, nonvolatile memory, installed on discharge pipe, etc.)    Gallons:     
12. Is a working pressure gauge provided? (Instant, installed on discharge pipe, etc.)    PSI:     
13. Is an adequate pump-to-waste provided? (Capacity of the well, air gap, prior to the first service connection, etc.)

Pump House Questions

Yes No N/A Unk
14. Is the well enclosed in a pump house?
15. Is the pump house protected from contamination? (Clean, in good repair, etc.)
16. Is the pump house protected from unauthorized entry? (Locked, durable construction, etc.)
17. Does the pump house have adequate lighting throughout?
18. Is adequate backflow protection provided on all threaded taps installed in the pump house?
19. Are there signs of equipment damage due to excess heat, moisture, or corrosion? (inadequate ventilation)
20. Is there a history of pump house equipment freezing? (Inadequate heating)
21. Is the pump house protected from flooding and surface water entry? (Floor drain, ground surface graded to lead surface water away, etc.)
22. Does the configuration of the floor drain or sump cause a contamination risk? (connected to other drainage systems, sump < 30 feet from well, etc.)

Springs

Spring Questions

Yes No N/A Unk
1. Is the spring recharge area protected from contamination? (Recommended)
2. Is a raw water smooth nosed sample tap provided? (Prior to any treatment)
3. Is a flow meter or other flow measuring device provided?

Spring Box Questions

Yes No N/A Unk
4. Is this Spring associated with a Spring Box?
5. How is the Spring Box Constructed?    Ground-Level     Below-Ground     Partially Buried     
6. What material is the Spring Box constructed of?    Concrete     Fiberglass     Metal     Plastic     Other     
7. Does a contamination risk exist due to wastewater spray irrigation or sludge disposal within 500 feet of the spring box?
8. Is the area within a 100 foot radius of the spring box protected from contamination? (Fenced, surface water diverted, no animals, no septic tanks, etc.)
9. Is leakage evident at time of inspection?
10. Is the inlet flowing adequately? (above sediment layer, clean screen, etc.)
11. Is the spring box protected from contamination? (watertight roof and sidewalls; excludes birds, animals, insects, and excessive dust; sloped roof for drainage; etc.)
12. Can the spring box be isolated from the system without depressurizing the distribution system?
13. Is an overflow provided and protected from contamination? (discharges to daylight, adequate air gap, 24 mesh screen or expanded metal screen with weighted flapper, etc.)
14. Do overflows discharge in a way to prevent erosion around the spring box? (Drainage structure or splash plate, air gap, etc.)
15. Is a drain provided for cleaning, maintenance, and inspection?
16. Do drains discharge in a way to prevent erosion and contamination around the spring box? (Drainage structure or splash pad, air gap, etc.)
17. Is the spring box secure from unauthorized access? (Fencing, locked manholes, etc.)
18. Is vegetation managed to prevent negative impact to the spring collection area? (Recommended)
19. Are access covers locked and prevent contamination? (2" overlapping cover, watertight, sealed, >24" above ground, etc.)
20. Is the area surrounding the spring box adequately graded? (divert surface water, minimize slope erosion)
21. Is the spring box properly vented? (opens downward >24" above roof or ground, 24 mesh screen, exclude insects, birds, and excessive dust)

Intakes and Infiltration Galleries

Intake Questions

Yes No N/A Unk
1. Is the area around the source restricted and clearly marked?
2. Are there any polution sources near the source?

Storage Tanks

Storage Tank Questions

Yes No N/A Unk
1. When was the storage structure last inspected?    Date:      
2. When was the storage structure last cleaned?    Date:      
3. Total Days Supply (This Structure)?    Days:     
4. How is the water level measured?       
5. Construction:    Above-Ground     Ground-Level     Partially Buried     Below-Ground     
6. Can the operator safely access the entire tank?
7. Does the storage structure appear to be structurally sound?
8. Is leakage evident at time of inspection?
9. Can the storage structure be isolated from the system without depressurizing the distribution system?
10. Does a contamination risk exist due to wastewater spray irrigation or sludge disposal within 500 feet of the storage structure?
11. Is vegetation managed to prevent impact to the storage structure? (Recommended)
12. Is the storage structure protected from contamination?
13. Is the storage structure secure from unauthorized access?
14. Does the drain discharge in a way to prevent contamination and erosion around the tank? (Discharge to daylight over drainage structure or splash plate, screened, adequate air gap, etc.)
15. Is an overflow provided and protected from contamination?
16. Does the overflow discharge in a way to prevent backflow and erosion around the tank?
17. Are access covers locked and protected from contamination? (>4" above the roof, 2" overlapping lid, watertight, tightly sealed, etc.)
18. Are vents provided and protected from contamination? (open downward >12" above roof and >24" above ground; 24 mesh screen; exclude animals, insects, birds, and excessive dust; etc.)
19. Are there signs or a history of the storage appurtenances freezing?
20. Are metal surfaces inside the tank corroding?
21. Are there any materials or components contacting water that may pose a contamination risk? (Paint, coatings, sealants, components, etc. NSF 61 Approved)
22. Is the area surrounding the storage structure graded to prevent standing surface water? (n/a for elevated tanks)

Partially burried or below ground storage

Yes No N/A Unk
23. Are manholes elevated to prevent contamination from snow, storm water, etc.? (>24" above the roof or ground)
24. Do potential contamination sources exist < 50 feet from the storage structure? (Sewer/irrigation lines, standing water, etc.)

Hydropnuematic Tanks

Hydropneumatic Tanks Questions

Yes No N/A Unk
1. Is the system served by variable speed pumps (VFDs)? (Recommended)
2. Is the tank located in a structure that is protected from flooding and unauthorized entry? (Locked, watertight walls and floor, floor drain, acceptable cover, etc.)
3. Can all hydropneumatic tanks be isolated from the system without depressurizing the distribution system?
4. Do the exterior surfaces appear to be in good condition? (Coating intact, no corrosion, etc.)
5. Do all tank supports appear to be structurally sound and adequate?
6. Have all hydropneumatic tanks been tested for structural integrity in the past 5 years? (Recommended)

Bladder Tanks Only

Yes No N/A Unk
7. Has the tank been tested for bladder failure in the last year?

Non-Bladder Tanks Only

Yes No N/A Unk
8. Is the recharge air protected from contamination? (free of air compressor oil, clean air filter, etc.)
9. Are installed appurtenances working properly and protected from contamination? (access manhole, drain, water sight glass, means to add air, air blow-off, etc.)

Distribution Systems

Distribution System Questions

Yes No N/A Unk
1. Main line type of materials are? (Select all that apply)    Steel     HDPE (black)     Asbestos/Cement     Copper     PVC     Ductile Iron     Gray Iron     Galvanized     Other     
2. Main line sizes?       
3. Number of Metered Connections?       out of     
4. Does the system utilize fire hydrants?
5. If yes, are mainlines a minimum of 6 inches?
6. Is a current map of the distribution system available? (Recommended)
7. Have public notifications, DEQ notifications, and follow-up actions been followed for any planned or unplanned depressurizations in the past year?
8. Was the pressure measured at a service connection?    PSI:     Location:     Time:      
9. Is a minimum system pressure of 20 psi. maintained at all service connections? (Including fire flow - Identify pressure complaints in the Notes.)
10. Is a minimum system pressure of 40 psi. maintained during maximum hourly demand conditions? (PWSs constructed after 7/1/1985 - Excluding fire flow)
11. Does pressure exceed 100 psi at any service connection?
12. Are valves inspected and exercised regularly? (Recommended)
13. Is the owner/operator aware of any leaking water mains?
14. Are all dead end mains equipped with a means to flush?
15. Are dead end mains flushed at least semiannually?
16. Are there any materials used that should not be in contact with drinking water? (Pipes, sealants, components, etc.)
17. Does the system experience water main freezing?
18. Are there any connections that provide supplemental disinfection and meet the definition of a PWS but are unregulated? (Recommended) (Hospitals, businesses, long-term care facilities, etc.)
19. Are there any unused subsurface water storage tanks that need to be abandoned? (Recommended)
20. Are there any water supply wells that are no longer being used that need to be abandoned? (Recommended)

Cross Connection Control

Yes No N/A Unk
21. Is an adequate cross connection control program provided and implemented? (Community PWS only) (Authority to implement, inspection program, adequate protection, annual testing,ability to discontinue service, 10 days to repair a failed device)
22. Is the operator trained in cross connection control? (Recommended)
23. Are all backflow preventers owned by the PWS tested annually?
24. Are there any known unprotected cross connections? (Submerged blow-offs, direct connections to storm or sewer drains, connection to unapproved source, uncontrolled fire hydrant use, treatment bypass with raw water, etc.)
25. Are all non-potable mains, hydrants, and taps easily identified as such?
26. Is the discharge piping on all air valves protected from contamination? (Prevent surface water entry and backflow, open downward, 24 mesh screen, etc.)
27. Are bulk water stations provided with backflow protection measures?

Pumps

Pump Questions

Yes No N/A Unk
1. Do any of the pumps cycle > 6 times per hour? (Recommended)
2. Are all pumps in good repair? (excessive noise, vibration, heat, odors, leaks, etc.)
3. Are spare parts readily available for critical pump components?
4. Is each pump equipped with an accessible check valve? (on the discharge side before the shut-off valve)
5. Are isolation valves provided on the discharge side of the pump?
6. Is a working pressure gauge installed on the discharge line of all pumps?
7. Is a working flow meter provided for each pump? (Required if pump is connected directly to the distribution system)
8. Is all pump lubrication oil ANSI/NSF 61 approved?
9. Is an air/vacuum relief valve provided for each vertical turbine pump and is it protected from contamination? (Open downward, 24 mesh screen, air gap, etc.)

Pump House

Yes No N/A Unk
10. Are there any pump houses associated with this PWS that don’t contain a Groundwater Source?
11. Are all pump houses protected from contamination? (Clean, good repair, etc.)
12. Are all pump houses protected from unauthorized entry? (Locked, durable construction, etc.)
13. Do all pump houses have adequate lighting throughout?
14. Is adequate backflow protection provided on all threaded taps/ hose bibs installed in any of the pump houses?
15. Are there signs of excess heat, moisture, or corrosion damage in any of the pump houses? (Inadequate ventilation)
16. Are there signs or a history of pump house equipment freezing in any of the pump houses? (Inadequate heating)
17. Are all pump houses protected from flooding and surface water entry? (Drained, ground surface graded to lead surface water away, etc.)
18. Do the floor drains discharge > 30 feet from any well in all of the pump houses?
19. Does an unprotected cross connection exist due to the floor drain connection in any of the pump houses? (Connected to sewer, storm drains, etc.)

Auxiliary Power Units (APU)

Yes No N/A Unk
20. Does the PWS have any APUs?
21. Are all APUs tested regularly? (Recommended)
22. For all APUs, is a working automatic power transfer switch provided?

Community Systems Only

Yes No N/A Unk
23. Can the community PWS adequately pressurize the distribution system during a power outage? (C only)
24. Do the APUs power all essential electrical functions in the pump houses and the pumping stations (pump, controls, treatment, etc.) and pressurize the system for a minimum of 8 hours?

APU on a Well Lot Only

Yes No N/A Unk
25. Are there any auxiliary power units located on a well lot?
26. Are the fuel tanks above ground or otherwise accessible for leak inspection?
27. Is secondary spill containment provided for all fuel tanks? (110% of fuel tank volume)
28. Does a certified operator observe filling of the fuel tank(s)?
29. Is engine exhaust directly discharged to the outside atmosphere for all APUs?

Treatment Plants

Treatment Questions

Yes No N/A Unk
1. Is water treatment required for public health protection?
2. Have there been any interruptions in treatment in the past year?
3. Were all alarms associated with treatment process equipment properly addressed? (Review treatment equipment alarm log(s) with the operator.)
4. How many gallons of water are treated per day?    GPD:     

Waste Handling and Disposal

Yes No N/A Unk
5. Does it appear that the water treatment plant waste is properly disposed of? (Sludge, backwash water, brines, spent treatment media, etc.)
6. Do any treatment processes, emergency overflow, drainage, or pump to waste features discharge to surface water or conveyances that have potential connection to surface water?

Sample Taps

Yes No N/A Unk
7. Are sampling taps provided for each treatment process?

Chemical Application

Yes No N/A Unk
8. Are chemicals applied in the treatment process?
9. Are chemical feeders in good condition with spare parts readily available for critical pump components?
10. Are the feeders manually or automatically controlled?    Manual     Automatic     
11. Does a flow sensing device prevent chemical injection when water flow stops?
12. If water flow rates vary, are chemical feed rates proportional to flow?
13. Are the quantities of chemicals used measured to detect over or under dosing?
14. Is backflow prevention provided on the water lines that discharge to solution tanks? (Air gap, internal feeder protection, etc.)
15. Is a working anti-siphon valve or equivalent on each feeder to prevent liquid chemical solutions from being siphoned or overfed into the water supply?
16. Is the chemical feed equipment easily accessible?
17. Are incompatible chemicals stored and handled separately?
18. Where multiple chemicals are used, are tanks and pipes clearly labeled to prevent accidental cross contamination?
19. Are chemical solution tanks protected from contamination? (Covered, sealed, etc.)
20. Are liquid chemical solution tanks provided with an overflow that is protected from contamination? (Open downward, 24 mesh screen, air gap, etc.)
21. Are vents from corrosive or hazardous chemical equipment discharged to the outside atmosphere above grade and remote from air intakes?
22. Are chemical shipping containers clearly labeled? (Chemical name, purity, concentration, supplier, ANSI/NSF 60 certified, etc.)
23. Are acids and caustics kept in closed, corrosion-resistant containers?
24. Is secondary spill containment provided for all bulk liquid chemical containers? (110% of container volume)
25. Is personal protective equipment provided for each operator? (Gloves, respirator, protective clothing, goggles or face mask, etc.)
26. Where provided, is the shower and eyewash station working?

Gas CL2

Gas CI2 Questions

Yes No N/A Unk
1. What is the Gas Chlorination type?    Pressure     Vacuum     

Protective Equipment

Yes No N/A Unk
2. Is respiratory protection equipment available and stored nearby, but outside of the chlorine room?
3. Does respiratory protection equipment consist of > 30 minutes of air and similar to the units used by the local fire department?

Chlorine Leak Detection

Yes No N/A Unk
4. Is a bottle of ammonium hydroxide provided? (56% ammonia solution)
5. Is a Chlorine Institute leak repair kit provided? (Emergency Kit "A" for 150 lb. cylinders and Emergancy Kit "B" for ton containers)
6. Is automatic chlorine gas leak detection equipment provided?
7. Is the automatic leak detector equipped with both an audible alarm and a warning light?
8. Does each chlorine cylinder have a valve that automatically shuts off the flow of chlorine gas, or is there an air treatment system for the chlorine room that automatically turns on, if a chlorine leak is detected?

Chlorine Room

Yes No N/A Unk
9. Is a sealed and separate room provided for gas chlorination equipment?
10. Are separate fan and light vandal-proof switches provided outside of the room and at the inspection window?
11. Are danger signs posted on all chlorine room doors and buildings?
12. Is a working ventilating fan provided?
13. Is the room vented at the floor with a ceiling air inlet across the room?
14. Does the ventilation fan discharge to outside areas that may be occupied? (Walkways, sitting areas, etc.)
15. Does the chlorine room door open outward by using a crash bar?
16. Do pressurized chlorine feed lines carry chlorine gas beyond the chlorinator room?
17. Is an interior shatter resistant inspection window provided?