Water Use Questionnaire

RESIDENTIAL CUSTOMERS
The purpose of this questionnaire is to help determine if you have any special plumbing or activities that may pose an increased risk of contamination to the water distribution system. Please respond by checking the appropriate box below:
Please provide the account number associated to the water service address.
Name(Required)
Please provide the primary account holders name.
Service Address(Required)
(recommended)

Plumbing or Activity Present on Premises

Please indicate whether the special plumbing or activities listed below apply to your premises. A 'Yes' or 'No' is required for each category below to successfully complete the form. This information is based on the current knowledge of the residential connections served. Public water systems may "customized" this list by adding or deleting plumbing categories or activities.
Underground Sprinkler System(Required)
Water Treatment System(Required)
(e.g. Water Softener)
Solar Heating System(Required)
Residential Fire Sprinkler System(Required)
Other Water Supply(Required)
(Whether or not connected to plumbing system.)
Sewage Pumping Facilities or Grey Water System(Required)
Boat Moorage with Water Supply(Required)
Hobby Farms or Animal Watering Troughs(Required)
Swimming Pool or Spa(Required)
Greenhouse or Decorative Pond(Required)
Photo Lab or Dark Room(Required)
Boiler or radiant heating system with makeup water(Required)
Booster Pump(Required)
Irrigation Well(Required)
Home-Based Business(Required)
(If Yes, please list the type/describe business below; e.g., beauty salmon, machine shop, etc.)
If you have checked "Yes" to any of the above, we will contact you to request further information. Your cooperation in completing this questionnaire is most appreciated.
If you have any questions, please contact the PUD at (360) 385-5800.
Date