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General Survey Form 1

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This is a sample sanitary situation survey form.

General Survey Form 1
General Survey Form 1
Sanitary Situation Survey
1. Community ______________________________________________________________
2. Address _________________________________________________________________
3. Property Owner_____________________________ Phone #______________________
4. Plat Map Identifier ________________ Acreage ______ Age of Home _______years
5. How long have you lived here ________years
6. How many bedrooms are in your home ________ How many live in your home______
7. Does your home have any of the following:
washing machine garbage disposal hot tub or spa in-ground lawn sprinkler
8. Is your washing machine connected to the septic system Yes No
If “No” where does it drain _______________________________________________
9. Is your hot tub or spa connected to the septic system Yes No
If “No” where does it drain _______________________________________________
10. Do you know approximately where your septic system is located Yes No
11. Is there parking or driving over any part of your septic system Yes No
12. Where does your drinking water come from Public system Private well
Shared well Other____________________________________________
13. About how old is your septic system 0-5 years 6-10 years
11-20 years More than 20 years Don’t know
14. Have you ever had your septic system repaired Yes No Don’t know
If “Yes” what was done _____________________________________________
_____________________ How much did it cost ________________
15. Have you noticed any of the following conditions related to your septic system:
Wetness in yard (unrelated to rain) Septic discharge Strong sewerage smell in yard
Slow drainage of your plumbing Sewage back-ups into home
Well water test shows positive for Fecal Coliform bacteria
16. When was the last time that your septic tank was pumped_________, and how much
did it cost__________ How often do you have it pumped __________________
17. Do you have a water softener Yes No
General Survey Form 1