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General Survey Form 1

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This is a sample sanitary situation survey form.

General Survey Form 1 Page 2
General Survey Form 1
Sanitary Situation Survey
2
18. Would you support the formation of a wastewater utility that would care for the
maintenance, repair, and even replacement of your septic system Yes No
If “Yes”, how much money would you be willing to pay, per month for this service
$0 $5 $10 $15 $20
19. Map: Show with approximate distances (in feet): buildings, driveways, roads, wells,
septic tank, drainfield, ditches, and ponds, etc.
_________________________________________ ____________________________________
Signature of Surveyor 1 Signature of Surveyor 2
________________________________________________ ___________________________
Signature of Property Owner Date
KEY NORTH
Building :
Drainfield : -----DF------
Septic tank : ST
Well : W
___________________
30 feet
How far away is the closest drainage ditch (as the crow flies) Less than 100 ft A few hundred yds Half mile or more
Are there areas or lines of greener, taller grass in the yard No Yes (show on map: GGR)
Are there any wet or spongy places in the yard that have a sewage odor No Yes (show on map: SP)
General Survey Form 1
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