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WATERSHED RESIDENTS QUESTIONNAIRE
1. Name M)C6- �wlS
2. Street Address (fy
O
3. How many members are in your household?
4.
What type of sewage disposal system do you have?
❑ cesspool
❑ septic tank and leaching area
L 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
101
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 I garbage disposal
dehumidifier drain sump pump toilet 1.7
roof/pavement drains shower/bathtub __9_
11. Please state the brand and type (liquid oryowder) of detergent you use for:
dishwasher PotgpE.r.
clotheswasher LiGzUi&— 05VA4 ' I �!6
12. Does your property have a lawn?
If yes, approximately whatsiz
Elless 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
❑ yes ❑ no
❑ 1/2 acre ❑ 3/4 acre ❑ 1 acre
acres
14. Please state
`
ate the brand and type (liquid or granular) of lawn fertilizer you use:
��
❑ Check here if your lawn is
by a professional landscape contractor.
1. Name
2. Street Address TO
3, flow many members are in your household?
4. What type of sewage disposal system do you have?
❑ cesspool
❑ septic tank and leaching area
V-,.- 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?
❑ ves ❑ 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
VC 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
3. 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
6ehumidifier drain sump pump toilet
rood/pavement drains showerlbathtub
11. Please state the brand and type (liquid orpowder) of detergent you use for:
dishwasher Ae4ga � — (' CRD
clotheswasher LiGiILO—
12. hoes your property
have a lawn? ❑ yes ❑ no
If yes, approximately what siz
❑ less than 1/4 acre '/4 acre ❑ 1/2 acre ❑ % acre ❑ 1 acre
❑ more than 1 acre (Specify) acres
13. H( -,w often do you fertilize your lawn?
Nc). of applications per year •�
Se,, son(s) of the year
14.
Ple; ase state the brand and type (liquid or granular) of lawn fertilizer you use:
S
ri C-1 eck here if your lawn is maintain d by a professional landscape contractor.