Name:

Job Ref: (if applicable)

Mobile:

Email Address:

Full Address (including Postcode)

Source of Enquiry:

Property Grid Reference: (Northing x Easting)

Private/Domestic Property: Private/Domestic Property: Private Property Domestic Property

Existing NIEA Consent: Yes/No (Ref.)

Commercial: Yes/No Commercial: Yes/No Yes No

Is Existing NIEA Consent void: Yes/No (Reason if No)

Development: (4 dwellings or more)

Is NIEA Consent required? Yes/No

New build: Yes/No New build: Yes/No Yes No

Existing SEPA Registration: Yes/No (Ref.)

Local Authority

Is Existing SEPA Consent void: Yes/No (Reason if No)

Government : Yes/No Government : Yes/No Yes No

Is SEPA Registration required: Yes/No (reason if No)

Does the building/site have planning permission: Yes/No (Ref.)

Does the building/site have building control approval: Yes/No (ref.)

Brief description of the property:

Is the property off-mains drainage? Yes/No Is the property off-mains drainage? Yes/No Yes No

Is the system septic tank? Yes/No Is the system septic tank? Yes/No Yes No

Is the system a W.W.T.P? Yes/No Is the system a W.W.T.P? Yes/No Yes No

Is the system on third party land? Yes/No Is the system on third party land? Yes/No Yes No

Is the system soakaway or direct discharge? Is the system soakaway or direct discharge? Soakaway Direct Discharge

Is there a legal easement in place? Yes/No Is there a legal easement in place? Yes/No Yes No

Brief description of the issues experienced: Note: If possible, take photos to show issues described above.

If off-mains packaged system how many times over the previous five years has the septic tank or WWTP been emptied?

Has the WWTP been serviced recently? Yes/No Has the WWTP been serviced recently? Yes/No Yes No

If served by a soakaway or drainage field has it ever been jetted out in previous 5 years? Yes/No If served by a soakaway or drainage field has it ever been jetted out in previous 5 years? Yes/No Yes No

Is a site assessment survey required? Yes/No Is a site assessment survey required? Yes/No Yes No

Development/ New-build: Yes/No Development/ New-build: Yes/No Yes No

House Sale Drainage Survey: Yes/No House Sale Drainage Survey: Yes/No Yes No

Bespoke Custom Design: Yes/No Bespoke Custom Design: Yes/No Yes No

Commercial or Public Use: Yes/No Commercial or Public Use: Yes/No Yes No

Insurance Claim Survey: Yes/No Insurance Claim Survey: Yes/No Yes No

Validation Survey: Yes/No Validation Survey: Yes/No Validation Survey: Yes/No Yes No

For Private Contract: Yes/No For Private Contract: Yes/No Yes No

Is a Vac-tanker required? Is a Vac-tanker required? Yes No

Is Jetting Gear required? Is Jetting Gear required? Yes No

Is CCTV & CAT-SCAN required? Is CCTV & CAT-SCAN required? Yes No

Is a mini-excavator required? Is a mini-excavator required? Yes No

Has a percolation Test to be carried out? Has a percolation Test to be carried out? Yes No

Is an outside water tap available? Is an outside water tap available? Yes No

Has a desktop study been carried out? Has a desktop study been carried out? Yes No

Is the property located on or in close proximity to any environmental or historically sensitive zones or areas? Is the property located on or in close proximity to any environmental or historically sensitive zones or areas? Yes No

Is the property on a flood risk zone? Is the property on a flood risk zone? Yes No

Is there a nearby mapped waterway? Is there a nearby mapped waterway? Yes No

Are there large trees close to the property? Are there large trees close to the property? Yes No

If WWTP proposed is there access to power supply? If WWTP proposed is there access to power supply? Yes No

How many metres from the tank to the nearest hard standing/driveway?

Is booking for survey confirmed? (please complete below) Is booking for survey confirmed? (please complete below) Yes No

Date:

Time:

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