Name:
Address:
City or Town:
State
Zip or Postal Code:
County:
Email:
How many kitchen sinks do you have?
One

Two

Three or More

None
How many kitchen faucets with a sprayer do you have?
One

Two

Three
How many ice makers do you have?
One

Two

Three
How many garbage disposals do you have?
One

Two

None
How many bathroom sinks do you have?
One

Two

Three or more
How many bathtubss do you have?
One

Two

Three or more

None
How many hot tubs do you have?
One

Two or more

None
How many toilets do you have?
One

Two

Three or more

None
How many boilers do you have?
One

Two

None
How many outside faucets do you have?
One

Two or more

None
How many non-freezing type outside faucets do you have?
One

Two or more

None
Do you have any permanent lawn irrigation systems?
Yes

No
Do you have a lawn fertilizer system?
Yes

No
Do you have a high pressure washer?
Yes

No
Do you have a private well?
Yes

No
If yes, is the private well physically connected to the water system?
Yes

No
Do you ahve any other helpul information regarding use of water?
Yes

No