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210/037.B-0013-0000.0
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WATERSHED RESIDENTS QUESTIONNAIRE
1. Name
2. Street Address / r''
i/
3. How many members are in your household? --
4. What type of sewage disposal system do you have?
❑ cesspool
2 septic tank and leaching area
❑ connection to municipal sewer
❑ other (describe)
❑ do not know
5. Are the plans (drawings) for y ur sewage disposal system on file with the Board of Health?
El yes El no for
not know
6. How old is your sewage disposal system? ❑ 0-5 years ❑ 6-10 years years
❑ over 20 years ❑ do not know
7. Has,your sewage disposal system been rebuilt or repaired?
2 yes ❑ no ❑ do not know
f
If yes, approximately how long ago? S years. What was done?
8. How frequently is your sewage disposal system pumped out? C annually
❑ every 2-4 years ❑ every 5-10 years, ❑ over 10 years ❑ never /
9. Have you had any problems with your sewage disposal system? [I yes 0 no
If yes, what problems?
❑ repeated pump-outs needed
❑ system clogs, backs up, or drains slowly
❑ odors
❑ sewage surfaces through ground
10. How many of each applare connected to your sewage disposal system?
washing machine 1ian_ dishwasher garbage disposal
dehumidifier drain sump pump toilet
roof/pavement drains shower/bathtub -
11. Please state the brand and type (liquid or powder) of detergent you use for:
dishwasher
clotheswasher - /
12. Does your property have a lawn? Lam' yes ❑ no
If yes, approximately what size?
❑ less than 1/4 acre ❑ 1/4 acre E?'1/2 acre ❑ 3/4 acre ❑ 1 acre
❑ more than 1 acre (Specify) acres
13. How often do you fertilize your lawn?
No. of applications per year -
Season(s) of the year -n ��-
14. Please state the brand and type (liquid or granular) of lawn fertilizer you use:
❑ Check here if your lawn is maintained by a professional landscape contractor.