WATER USER SURVEY

COMPLETE ONE DATA SHEET FOR EACH WATER SERVICE LOCATION

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Name of Property OwnerPhone Number

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(Street) or (Route & P.O. Box)

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CityStateZip Code

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Name of person living on propertyPhone Number

(Renter, Contr./Deed Purchaser, Owner)

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(Street) or (Route & P.O. Box)

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City StateZip Code

Do you desire to become a member of the rural water system? ______

If no, state reasons: ______

  1. Present Water Supply:

1. Estimate total present water usage for all purposes in gallons:

Monthly ______

  1. What is present water source? ______
  2. Describe quantity and quality of water: ______

Describe odor: ______Describe Taste: ______

Do you Soften? ______Does it Stain Fixtures? ______

4.What do you estimate is the total cost you have incurred in looking for and/or developing your present water supply? ______

  1. What do you estimate is your present total annual cost for water? ______

II.Please indicate with a dot on the sketch the location where you would want water service:

1.If service is rural:

Sec. No. _____ TWP Name: ______

TWP. No. ______Range No. ______

  1. If service location is in a rural city or subdivision:

City or Subdivision: ______

Lot No. ______Block No. ______

III. Water Use Information.

  1. HOUSEHOLD USAGE:

Number of persons ______

  1. LIVESTOCK USAGE:

Present Livestock Numbers / Foreseeable Future Livestock Numbers (be as accurate as possible)
Feeder & Beef Cattle
Hogs
Dairy Cattle
Turkeys
Poultry
Horses
Sheep
  1. How much water do you wish to buy from the rural water system?

Here again, be as accurate as possible, and circle the answer that best describes your expected usage:

Present Livestock Usage-(All)(3/4)(1/2)(1/4)(None) (Standby)

Foreseeable Livestock Usage- (All)(3/4)(1/2)(1/4)(None) (Standby)

4.If you wish water for livestock on a standby basis only, would you be willing to pay a higher minimum for it? ______Yes ______No

  1. Other major usages, if any – Please itemize and explain – Estimate gallons per day: ______

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Remarks: ______

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Date: ______Signed (Water User): ______

Check: ______Cash: ______Signed (Canvasser): ______

Date Received: ______