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