Septic Tank Adjustment Questionnaire
Septic Tank Adjustment Questionnaire
Name
*
First
Last
Address
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Afghanistan
Albania
Algeria
Andorra
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo
Costa Rica
C?te d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia and Montenegro
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
Country
Phone
*
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Email
*
Please answer all questions as honestly as you possibly can. It is the best way we can help you get your septic system’s fermenting process to a good fermenting performance. All the information is used and kept within our educational system only for processing and solving your present and probable future septic problems that will occur if you don’t maintain your septic system.
How big is your septic tank? (Gallons)
How many septic tanks?
How many leach fields service this application?
How many bedrooms in your house?
How many people live in the house?
Is the home your permanent residence?
Yes
No
Is the home used mainly on weekends?
Yes
No
Is it a seasonal home?
Yes
No
If yes, how many months in:
Summer
Winter
Spring
Fall
Do you have guests often?
Yes
No
If yes, how many per week and per month?
Do any of the following go into the septic tank?
Washing Machine Discharge
Yes
No
If yes, is the machine High Efficiency?
Yes
No
N/A
Bathroom sinks, tubs, and/or showers (Known as Gray Water)
Yes
No
Kitchen sink (Known as Black Water-This should always go into the Septic Tank because of food & grease mixed in water)
Yes
No
Water softener
Yes
No
Other type of softener?
Yes
No
If yes, what type?
If yes, what kind of salt?
Regular Salt
Potassium Salt
Other
Chlorinator discharge (Used to remove bacteria)
Yes
No
If yes, what type? If yes, product(s)/process used
Carbon conditioner discharge (used to remove harmful chemicals)
Yes
No
Air conditioner discharge
Yes
No
Dehumidifier discharge
Yes
No
Dehumidifier discharge, Attached to hot air furnace?
Yes
No
Sump pump discharge
Yes
No
Fish tank discharge
Yes
No
Freezer, refrigerator, or icemaker discharge
Yes
No
Laundry soap detergent
Yes
No
Do you use 100% biodegradable soap for the following (check all that apply)
Laundry
Personal body soap
Shampoo and/or conditioner
Dish soap
Floor and other cleaning soaps
Toilet cleaners
Do your use Chlorine in your cleaners?
Yes
No
Do your use vinegar in your cleaners?
Yes
No
Identify by listing all the the types of cleanrers you use
Is anyone on an antibiotic medicine for more than 30 days?
Yes
No
What type of antibiotic and for how long?
How often is your septic tank pumped?
Is it totally pumped out?
Yes
No
Your last pumping was a service pumping or emergency pumping?
Service
Emergency
If it was an emergency, what were the signs that made you think you needed a pumping?
Back up in the home
Odor
Gurgling noise
If Other - explain below
Other
How often do you or someone else inspect your septic tank for structural condition?
How often is it inspected for how well the fermenting process is working?
Does your pumping contractor give you a written report?
Yes
No
If yes, does the report include identifying pictures if there is a problem?
Yes
No
If yes, email us those reports & pictures to better serve and advise you.
When the septic tank is pumped, are all the openings exposed? (especially the inlet and outlet) (After 10 years an Outlet Structural Inspection is strongly recommended)
Yes
No
Are you having a septic problem now?
Yes
No