LOWA Septic Tank Pump-Out Survey Form
Please fill out the below requested information.
Date:
Your e-mail:
Your Name:
Your telephone number:
Best Time To Call:
What is your Address:
Street Address:
City,State, and Zip:
Do You Own This Property?
Yes
No
How many people use
water daily here?:
Do you live here:
Full time?
Full Time
Part time?:
Part Time
If part time
How many days/year?:
Water System
Do you have a well?:
Yes
No
Is water tested annually?
Yes
No
Is the well metered?
Yes
No
Public Water System?:
Yes
No
Estimate how many gallons per month are used in the household?
gals/month?:
Wastewater System
Do you have a septic tank? :
Yes
No
If "Yes", answer the following questions:
How old is it in years?:
What is its capacity size in gals?:
What material is it made of?:
Has your tank been pumped out?:
Yes
No
If yes, how many years is
it between pump-outs?:
How long has it been
since the last pump-out?:
Who was the pumping
company?:
FILL OUT AS MUCH OF BELOW INFO AS POSSIBLE
Do you have a lateral field?
Yes
No
Do you have a pump vault and pump?
Yes
No
Is your tank easily accessible? Ex. Near a road or driveway
Yes
No
How many feet is your septic tank away from the lake or a stream?:
How far is your septic tank away from your well?
Does your tank have a riser easily accessible?
Yes
No
If you have a friend or neighbor who may be interested in a septic pump out,
please enter their name and phone number below:
Name:
Phone:
Please provide directions to your property: