Septic Tank Adjustment Questionnaire

Name * First Last
Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Phone * - (###) - ### ####
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

Septic Tank Adjustment Questionnaire

Septic Tank Adjustment Questionnaire

If yes, how many months in:

Do any of the following go into the septic tank?

If yes, email us those reports & pictures to better serve and advise you.