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SEPTIC SYSTEM INSPECTION FORM
ADDRESS 46S- C -
DATE INSPECTED
PROPERLY FUNCTIONING? N
WEATHER CONDITIONS
COMMENTS:
WATER QUALITY TESTED? RESULTS?
DYE TEST PERFORMED? Y .N
DATE?
SKETCH:
WATERSHED RESIDENTS QUESTIONNAIRE
1. Name W T_Vj A/C i
2. Street Address 5 G7 F_&_ JY0 l�D
T� r
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 ❑ do not know
7. Has your sewage disposal system been rebuilt or repaired?
❑ yes 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
❑ 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 — shower/bathtub _
11. Please state the brand and type (liquid or powder) of detergent you use for:
dishwasher L /A 1,C
clotheswasher L I-
12.
12. Does your property have a lawn? yes ❑ no
If yes, approximately what size? --
X less than 1/4 acre ❑ 1/4 acre ❑ 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
Z"':If ,R%
14. Please state the brand and type (liquid or granular) of lawn fertilizer you use:
`Lc?✓;2S
❑ Check here if your lawn is maintained by a professional landscape contractor.