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WATERSHED RESIDENTS QUESTIONNAIRE
1. Nameil�/,�'L.f/G��
2. Street Address�'X�LL
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3. How many members are in your household? -�
4
What type of sewage disposal system do you have?
❑ cesspool
❑ septic tank and leaching area
X 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 K do not know
7. Has your sewage disposal system been rebuilt or repaired?
❑ yes ❑ no X 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
O9. Have you had any problems with your sewage disposal system? ❑ yes I 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 p sump pump toilet �3
roof/pavement drains 63 shower/bathtub
11. Please state the brand and type (liquid or powder) of detergent you use for:
dishwasherR
clotheswasher Qii zpc✓S
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 ❑ 3/4 acre ❑ 1 acre
❑ more than 1 acre (Specify) - acres
13. How often do you fertilize your lawn?
No. of applications per, ear /._
OSeasons) of the year,
14. Please state the brand and type (liquid or granular) of lawn fertilizer you use:
19. Check here if your lawn is maintained by a professional landscape contractor.
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