Lesson 2 - Septic System Preclass Evaluation Form Activity
Acknowledgement: Taken from "Living on the Land 2001"

Name __________________________________________________________________

Address ________________________________________________________________

1.      Number of people living in home ______ Adults _____ Children _____Male _____ Female

2.      Garbage disposal used (circle)?    ____ No    ____ Yes

3.      Water softener (circle)?    ____ No    ____ Yes    If yes, backflushes to: ___________________

4.      Dishwasher (circle)?    ____ No    ____ Yes

5.      Loads of laundry ___________ per day ______ per week

6.      Bleach used (circle)?    ____ No    ____ Yes    If yes, how many cups per week?  ____________

7.      Antibacterial soap used (circle)?    ____ No    ____ Yes

8.      Number of rolls of toilet paper used per week __________________________________

9.      Please list commonly used cleaning supplies __________________________________

10. Well location, depth and amount of casing ____________________________________

11. Is this your first home with on on-site septic system (circle)?    ____ No    ____ Yes

12. Age of septic system ____________________________________________________

13. Number of septic tanks __________________________________________________

14. Septic tank capacity _________________gallons

15. Last date of septic tank pumping ___________________________________________

16. Location of leachfield ____________________________________________________

17. Number of bedrooms ____________________________________________________

18. System ever backed up (circle)?    ____ No    ____ Yes    If yes, when? ___________________

19. System ever repaired? )?    ____ No    ____ Yes    If yes, when?_________________________

Adapted from University of Wisconsin, http://www.bae.umn.edu/~septic/Homeowner/homeowner%20survey.html

(top)