Water Quality
Module 3

Lesson 1- 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)? o___ 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?

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