3333 Kishwaukee St., Rockford, IL 61109

Phone: 815/387-7500  Fax: 815/387-7513

Clearwater Inspection Form – Account Transfer /New Account

Required by RRWRD Code of Ordinances, Title 3, Article III, Section 2, 11a
F  To be completed by an Illinois-licensed plumber   E

Building Address: ________________________________________                                Date: _______________________
City, State, Zip: __________________________________________                       

Owner / Contact Information:

Multi-Family or Commercial  Building

Name: ___________________________________________

Address: _________________________________________

City, State, Zip: ___________________________________

Phone:  Home: _______________ Work: _______________

Common Sewer Service            Y                  N

If yes, please list all addresses served.

________________________________________________

________________________________________________

Building Type:            _______ Single Family
                                        _______ Multi-Family
                                        _______ Commercial
                                        _______ Industrial

                                    _______ Other ___________________

New Construction                    Y                      N

For New Construction, all internal plumbing must be in place prior to certification.

1.  Roof Drain Discharges to Sanitary Sewer                                                           Y                 N

2. Foundation Drain Discharges to Sanitary Sewer                                                 Y                 N

3. Storm/Ground Water Sump Pump Discharges to Sanitary Sewer                     Y                 N

4. Combination Storm/Sanitary Pump Discharges to Sanitary Sewer                   Y                 N

5. Diverter Valve on  Storm Water Sump Pump Discharge                                    Y                 N

6. Sanitary Sewer Sump Pit Without Sealed Bottom                                               Y                 N

7. Flexible Discharge Hose on Storm/Ground Water Sump Pump                         Y                 N

Plumber Information:  Plumber Name: __________________________________________________________________

Plumber’s License No.:  _____________________________    Company Name: __________________________________

Address:____________________________________________________________________________________________

(List Plumber or Company Address, as applicable )

Proper Connection    : ______   Certification of Compliance with RRWRD Code of Ordinances, Title 2, Article III, Section I, A

Improper Connection: _____   Building does NOT meet RRWRD Code of Ordinances, Title 2, Article III, Section I, A

Plumber’s  Signature : ___________________________________________ Phone ______________________________

INSPECTION FORM NOT VALID WITHOUT SIGNATURE

And Complete Plumber Information

Certification Valid for One Year from Date of Inspection