This Survey assesses the risk to groundwater quality posed by your household wastewater treatment on the basis of the answers to the survey questions. Please answer all questions for a fair evaluation.

Quantity and Quality of Effluent (Wastewater):

1. How much wastewater is generated in your household?

Less than 25 gallons per person per day
25 to 100 gallons per person per day
Over 100 gallons per person pe day		 Corresponding magnitude of risk

2. Do any or your water fixtures drip or leak?

Yes
No		 Corresponding magnitude of risk

3. Have you installed any water conserving fixtures in your home?

Many
Some
None		 Corresponding magnitude of risk

4. How many times  a week is your water softener set to recharge?

Twice or less
More than twice		 Corresponding magnitude of risk

5. Approximately how many times do you use a kitchen garbage disposal per week?

2 times or less per week
3 to 5 times per week
Daily		 Corresponding magnitude of risk

6. How much household chemicals (cleaners, detergents, etc.) do you add to the wastewater?

None
Cups per week
Quarts or more per week		 Corresponding magnitude of risk

7. How much toxic cleaning agents and solvents (paint thinner, etc) are added to the

None or minimal amounts
Moderate amounts
Extensive amounts		 Corresponding magnitude of risk

8. How often (or amount) do you dispose of oils and greases into the sink or sewer?

Minimal amount/seldom
Moderate amount/occasional
Extensive amount/frequent		 Corresponding magnitude of risk

Collection and Pretreatment of Effluent:

9. Select the answer that best describes your collection system?

All wastewater and some clear water collected for treatment. No leaks
Some wastewater diverted or some leakage of water. Clear water infiltration
Clear water infiltration. Leakage loss of water that should be treated.		 Corresponding magnitude of risk
 

10. How far is the collection system from the well?

More than 50 feet
25 to 50 feet
Less than 25 feet		 Corresponding magnitude of risk

11. Which collection/pretreatement of system do you use?

Direct discharge to the surface, ditch or stream
(Stop here if you selected the above option; Surface discharge of untreated effluent is a violation of Indiana Code. Risk is very High! )
Septic Tank		 Corresponding magnitude of risk
 

12. Select the response that best describes your septic tank system.  

Tank is more than 50 feet away from the well. Serial tanks or added retention system. Pumped every three years or less.
& No leakage. Baffles and tank inspected regularly.
Tank located 26 to 50 feet from well. Single tank. Pumped every 4 to 6 years
Less than 25 feet from well. Leakage. Tank pumped every 7 or more years. Tanks located 3 feet from water table or bedrock.		 Corresponding magnitude of risk

Liquid Waste Disposal:

13.Do you dispose of the liquid portion of the wastewater on your farm?

Yes
No		 Corresponding magnitude of risk

14. Which method of liquid disposal do you use?

Subsurface application or soil absorption.
Distibuted on land surface ( If you selected this option, skip questions 15 thhrough 20 and move on to question 21)		 Corresponding magnitude of risk

15. What system of subsurface appllication of liquid waste do you use?

Trench system
Cesspool, drywell, seepage pit or bed
Draiange tile		 Corresponding magnitude of risk

16. What is the texture of the soil at the liquid waste application site?  

Loam
Clay
Sand		 Corresponding magnitude of risk

17. Is your liquid disposal area downslope from the water well?

Yes
No		 Corresponding magnitude of risk

18. Is your liquid waste disposal more than 50 feet from the water well?  

Yes
No		 Corresponding magnitude of risk

19. Do you apply the liquid waste at a rate below, equal to or above the design capacity of the system?  

Below
Equal
Above or uncertain		 Corresponding magnitude of risk

20. Do you have seasonal problems with slow operation and wet areas in the yard or effluent discharge area?

Yes
No		 Corresponding magnitude of risk

21. Do you apply liquid wastewater to the land surface or ditch?  

Yes
No (if you selected 'No', please skip question 22 and go to question 23)		 Corresponding magnitude of risk

22. Do you have a state permit (IDEM) for surface application of domestic wastewater?

Yes
No (If you selected 'No', stop here; Surface application without a permit and approved disposal system is a violation of Indiana Code. Risk is high!!)		 Corresponding magnitude of risk

23. Do you dispose of hte solid sludge portion of wastewater on your farmstead?

Yes
No (if you selected 'No', please stop here)		 Corresponding magnitude of risk

24. Do you have a state permit (IDEM) for surface application of sludge?  

Yes
No		 Corresponding magnitude of risk

25. What is the soil texture of the sludge disposal site?  

Loam
Clay
Sand		 Corresponding magnitude of risk

26. Is the slludge disposal site more than 200 feet from the well?

Yes
No		 Corresponding magnitude of risk

 
Net Survey Score:
Magnitude of Risk:

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