HomeMy WebLinkAboutMiscellaneous - 325 JOHNSON STREET 4/30/2018V'X'7ATERSHELD RESIDE_!\, -1 QUESTIONNAIRE
1. Nani e \f` LY— X) • L_ilobpo
2.
Street Address ��-�
��}�1`s,o
�0 D�O 0S-
3.
HcPw many members are in your
household?
Z-
4.
1'E, at type of sewage disposal system do you have?
cesspool
P-. 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?
X 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 ❑ do not know
7. Has your sews a disposal system been rebuilt or repaired?
« yes no ❑ do not know
yes, approximately how long ago?
years. What was done?
8. How frequently is your sewage disposal system pumped out? ❑ annually
X 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. if ow many of each appliance are connected to your sewage disposal system?
,dashing machine dishwasher garbage disposal
6e.humidifier c►rain sump pump a toilet 3
roof/pavement drains 0 showerlbathtub -Z-
11.
11. please state the brand and type (liquid or powder) of detergent you use for:
dishwasher CPQ S L-f�pC
clotheswasher `71 t�
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? wn?
No. of applications per year
Season(s) of the year
1� yes ❑ no
❑ 1/2 acre X 3/4 acre ❑ 1 acre
acres
14. Please state the brand and type (liquid or granular) of lawn fertilizer you use:
1.3 %
❑ Check here—if your lawn is maintained by a professional landscape contractor.
j WATERSHED RESIDENTS QUESTIONNAIRE
1. Name�L� ��• ila��li
2. Street Address Z- 'z' 1�3.i � N - ►`�`� cQ2
3. How many members are in your household? �-
4.
What type of sewage disposal system do you have?
❑ cesspool
9 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?
X 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 ❑ do not know
7. Has your sewage disposal system been rebuilt or repaired?
0 yes �e�
no ❑ do 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
;K odors
❑ sewage surfaces through ground
10. How many of each appliance are connected to your sewage disposal system?
washing machine dishwasher garbage disposal �z
dehumidifier drain sump pump toilet
roof/pavement drains 0 shower/bathtub Z
11. Please state the brand and type (liquid or powder) of detergent you use for:
dishwasher CA -��-
clotheswasher�-
12. Does your property have a lawn? yes ❑ no
If yes, approximately what size?
❑ less than 1/4 acre ❑ 1/4 acre ❑ 1/2 acre X 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
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.
SEPTIC SYSTEM INSPECTION FORM
ADDRESS 2)25-
25- j 6 (!s8 Y -N
DATE INSPECTED` Dl0
PROPERLY FUNCTIONING? Y N
WEATHER CONDITIONS
COMMENTS:
CA -
lis .�fQ
1 �� sa r,tie a. +-� t�S
zs
DYE TEST PERFORMED? Y N
DA'Z'E?
SKETCH:
T
20' -25'
30 (4di
3 xs- j &k,, Sf
Please forward us as much of the followna information that is possible;
1. Type of system
2. Age A'o, `/4,
3. Location-
4. Maintenance records ar.
. / v v xlel
5. Documentation of repair
b. Site conditions k -GW
7. $wilder of system
8. Engineer who approved%
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9. Installation Procedvre
10. Problems
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SEPTIC SYSTEM INSPECTION FORM
V
ADDRESS
DATE INSPECTED
PROPERLY FUNCTIONING? Y N
WEATHER CONDITIONS
COMMENTS: t
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co vo �- e l d � C i�-�- ,-ems
WAi c` -t, aZ;ALi i CS ► c�' f;ES� i S?
DYE TEST PERFORME ? Y N
SKETCH,
DATE?
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