SEP-CHK-1000 Homeowner Survey
Self-assessment and risk screening for septic system inspection and maintenance. Please complete all sections.
Section 1 – Property, Ownership & System Basics
Property address
*
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Municipality / County
*
Approximate year home was built
Year current owner since
Number of bedrooms
*
Number of high-volume fixtures (e.g., tubs, soaker tubs, high volume showers)
If known, enter the approximate total volume of water used each month in the home (include measure of imp gal/Liters)
Septic system type
*
Gravity (leach field / trench)
Pressure distribution
Mound system
At-grade system
Chamber system
Unknown
Approximate disposal field size or number of laterals, if known (ie. 4 lateral runs approximately 100 feet long)
Is a high-level alarm installed?
Yes, alarm installed and tested
Yes, installed but not tested
No alarm installed
Unsure if alarm present
Section 2 – Occupancy & Water Use
Number of full-time occupants
*
Has there been a recent change in occupancy?
Yes
No
If yes, describe the change:
Food garburator / garbage disposal installed?
Yes
No
Has the home been vacant at any stages? Please describe:
Laundry frequency and pattern
1–2 loads per week
3–4 loads per week
5–7 loads per week
8+ loads per week
Multiple loads completed in a single day (3+ loads/day)
Large back-to-back laundry days common
Section 3 – Water Source & Setback Awareness
Water source
*
Municipal water
Private drilled well
Dug or bored well
Cistern
Are you uncertain of the well-to-field distance?
Yes
No
Enter the Distance from well to field if known
Are you uncertain of the tank-to-well distance?
Yes
No
Enter the tank-to-well distance if known
Section 4 – Municipal Additives & Chemistry
Community Name (ie. Pinewood Estates)
Are you aware of corrosion-control additives (e.g., orthophosphate) in your water supply?
Yes
No
Unsure
Section 5 – Water Treatment & Additives
Is a water softener installed?
Yes
No
Does the water softener discharge to the septic system?
Yes
No
Unknown
Softening agent used
Sodium-based
Potassium-based
Unknown
Is a reverse osmosis (RO) system installed?
Yes
No
Does the RO system discharge to the septic system?
Yes
No
Unknown
Section 6 – Observed System Symptoms
Observed symptoms (select all that apply)
History of sewage backup
Slow draining fixtures
Septic odours (inside or outside)
Wet or soft areas over septic field
Surface ponding observed
Unusually lush vegetation over field
Long pump cycle times
Describe if you get any seasonal pooling in your yard that doesn't drain quickly, and note if this is near your drain field (ie. spring melt, heavy rains) and describe in as much detail as possible how long it takes to drain or any other details.
How long have you noticed these symptoms?
1 month
3-6 months
1 year
2 years or more
Are there any trees near your disposal field? Describe in as much detail as possible the number and size of trees and proximity to your drain field.
Section 7 – Maintenance & Access
When was the last septic tank pump-out?
Within 2 years
2–5 years ago
Over 5 years ago
Unknown
Are tank lids visible and safely accessible?
Yes
No
Are risers installed 8 inches above grade?
Yes
No
Unknown
Was excavation required to access the tank?
Yes
No
Describe the type of riser access to your tank
Risers with lids over each chamber
Single riser over both chambers, with baffle wall clearly visible
What material are your risers made from?
Plastic
Concrete
Other
Describe the condition of your risers
Good Condition - secure, no visible cracks or damage
Minor wear – slight surface damage, but still functional
Needs repair – visible cracks, loose or poorly fitting lid
Damaged or broken – missing lid, severe cracks, unsafe
Not sure / Unable to inspect
How wide if your riser access (this helps us to determine access if any equipment or repairs are recommended)
Have you been given any orders to repair your septic system?
Yes
No
Add any pictures you have of the symptoms or system design
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Preliminary risk level
Low preliminary risk
Moderate preliminary risk
Elevated preliminary risk
Escalation recommendation
Tier 2 Walkaround & Visual Inspection Recommended
No escalation recommended at this time
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