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HomeMy WebLinkAboutMiscellaneous - 255 SALEM STREET 4/30/2018 (2)N O O N W � V O D o m K CO b - o M o m o m o WATERSHED RESIDENT'S QUESTIONNAIRE 1. Name / 6NCR'�Fz" e I_ 2. Street Address Z � SJ4757: 3. How many members are in your household? 4. What type of sewage disposal system do you have? ❑ cesspool ❑ septic tank and leaching area 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 6. How old is your sewage disposal system? ❑ 0-5 years ❑ 6-10 years ❑ 11-20 years ❑ over 20 years X do not know 7. Has your sewage disposal system been rebuilt or repaired? ❑ yes ❑ no >rdo not know If yes, approximately how long ago? 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? ❑ yes 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 appliance are connected to your sewage disposal system? t washing machine —j— dishwasher ' �_ ' garbage disposal dehumidifier drain sump pump toilet -_ roof/pavement drains shower/bath b '2 WMA, Alam 11. Please state the brand and type (liquid or powder) of detergent you use for: dishwasher C* e."E " lAW1 *411 clotheswasher VAS r. — ;%tCQj I b 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 , 0 Season(s) of the year []Ryes ❑ 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: Check here if your lawn is maintained by a professional landscape contractor. 4. Wh l- tyle of sewage disposal system do you have? ❑ cessipool. ❑ Peptic tante and leaching area �. Q� connection to municipal sewer ❑ other (describe) ❑ o not know 5. 1,-rc the plans (drawings) for your sewage disposal system on file with the Board of Health? ❑ yes ❑ no do not know 6. 1 -low old is your sewage disposal system? ❑ 0-5 years El 6-10 years El 11-20 years ❑ over 20 yearsX do not know 7. Has your sewage disposal system been rebuilt or repaired? ❑ yes ❑ no do not know ye= approximately how long ago? years. What was done? f,. E, ow frequently is your sewage disposal system pumped out? ❑ annually ❑ every 2-4 years Elevery 5-10 years Elover 10 years ,,'never 5. have you had any problems with your sewage disposal system? El yes no 1: yes, what problems? ❑ repeated pump -outs needed ❑ system clogs, backs up, or drains slowly ❑ odors ❑ sewage surfaces through ground 10. 1- ox - many of each appliance are connected to your'sewage disposal system? is r: ing machine _ dishwasher'- garbage disposal 6 .-h. ddifier drain sump pump toilet�� ro.3,',pavement drains shower/bathtub A FILM 11. Pease state the brand and t pe (liquid or powder) of detergent you use for: siis'o.washer *Se �� P ciotheswasher WMS 12. Hoes your property have a lawn? ❑yes ❑ no If yes, approximately what size? ❑ less than '/4 acre ❑ 1/4 acre ❑ '/2 acre ^Na"^3/4 acre ❑ 1 acre ❑ more than 1 acre (Specify) acres 13. 1-1v-, : often do you fertilize your lawn? N ;: ,cif applications per year S:=G on(s) of the year 14. 1:. state the brand and type (liquid or granular) of lawn fertilizer you use: Ci-..,I-ck here if your lawn is maintained by a professional landscape contractor. �. l�alsiC 2. Street Address e 3. Hov, many members are in your household? 4. Wh l- tyle of sewage disposal system do you have? ❑ cessipool. ❑ Peptic tante and leaching area �. Q� connection to municipal sewer ❑ other (describe) ❑ o not know 5. 1,-rc the plans (drawings) for your sewage disposal system on file with the Board of Health? ❑ yes ❑ no do not know 6. 1 -low old is your sewage disposal system? ❑ 0-5 years El 6-10 years El 11-20 years ❑ over 20 yearsX do not know 7. Has your sewage disposal system been rebuilt or repaired? ❑ yes ❑ no do not know ye= approximately how long ago? years. What was done? f,. E, ow frequently is your sewage disposal system pumped out? ❑ annually ❑ every 2-4 years Elevery 5-10 years Elover 10 years ,,'never 5. have you had any problems with your sewage disposal system? El yes no 1: yes, what problems? ❑ repeated pump -outs needed ❑ system clogs, backs up, or drains slowly ❑ odors ❑ sewage surfaces through ground 10. 1- ox - many of each appliance are connected to your'sewage disposal system? is r: ing machine _ dishwasher'- garbage disposal 6 .-h. ddifier drain sump pump toilet�� ro.3,',pavement drains shower/bathtub A FILM 11. Pease state the brand and t pe (liquid or powder) of detergent you use for: siis'o.washer *Se �� P ciotheswasher WMS 12. Hoes your property have a lawn? ❑yes ❑ no If yes, approximately what size? ❑ less than '/4 acre ❑ 1/4 acre ❑ '/2 acre ^Na"^3/4 acre ❑ 1 acre ❑ more than 1 acre (Specify) acres 13. 1-1v-, : often do you fertilize your lawn? N ;: ,cif applications per year S:=G on(s) of the year 14. 1:. state the brand and type (liquid or granular) of lawn fertilizer you use: Ci-..,I-ck here if your lawn is maintained by a professional landscape contractor.