Private Wastewater System

Private Wastewater System

Homeowner Declaration Form
Customer Details:
Full Name*

First NameLast Name
Mailing Address *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number*
Mobile Phone Number
E-mail Address*
example@example.com
Site Details:
Site Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Legal Land Description
Lot: Type a label* Block: Type a label* Plan: Type a label*
Building Details:
House Size (square feet)*
Current Number of Occupants*
Bedrooms (Total)*
Bathrooms (Total)*
Do you currently have a water softener?*

YesNo
Do you currently have an iron filter?*

YesNo
Do you currently have a reverse osmosis (RO) system?*

YesNo
Do you currently have a garburator?*

YesNo
Do you have any of the following High-Water-Use fixtures? (Select ALL that apply)*

Hydromassage / Soaker TubsHot Tub / PoolSteam / Multi-Head ShowersOther
If you answered YES to any of the above options, please indicate how many of each and describe the unit to the best of your knowledge.
What is your MAIN water source?*

Drilled wellCisternMunicipal
Do you have any other buildings on the property? (If YES, please describe what they are and their approximate size)
Do you have a home based business?*

YesNo
If YES, please describe your business and it's day-to-day activities.
Please describe any home based hobbies. (Ex: Beer/Wine making, canning, etc.)*
Please describe your lifestyle. (Ex: Dinner parties, entertaining, excessive laundry from sports, etc.)*
Are there any specific covenants or easements on your property that we should know about?*

YesNo
If YES, please describe.
Future Building Plans:
Do you plan to build any additions onto your home or outbuildings?*

YesNo
If YES, please describe the addition plans.
Bedrooms (Total)
Bathrooms (Total)
Do you currently have a water softener?

YesNo
Do you currently have an iron filter?

YesNo
Do you currently have a reverse osmosis (RO) system?

YesNo
Do you currently have a garburator?

YesNo
Do you have any of the following High-Water-Use fixtures? (Select ALL that apply)

Hydromassage / Soaker TubsHot Tub / PoolSteam / Multi-Head ShowersOther
If you answered YES to any of the above options, please indicate how many of each and describe the unit to the best of your knowledge.
Do you have a home based business?

YesNo
If YES, please describe your business and it's day-to-day activities.
File Upload:
Building Plans (Any architectural or engineered drawings for your current or future building plans, etc.)

Cancelof
Septic System Designs/Existing System Information (Upload any current/future designs, existing shop drawings, past and present permits, etc.)

Cancelof
OTHER: (Upload any other files or information you think we need to know)

Cancelof
Authorization:
I hereby certify that the information provided is true and complete to the best of my knowledge. I authorize the verification of any or all information contained herein as necessary.
Date*

MonthDayYear
Date
Signature*

Clear
Please verify that you are human*
Should be Empty: