Septic System Assessment

 

All fields marked in yellow are required to be completely filled out or the form cannot be sent. Input n/a if not applicable. Upload plot plan or email to us directly at dswastewaterdesign@gmail.com.

 

Homeowner Declaration Form

- Client Information -

 
Date:
 
Owner/Client Name:
 
Who is filling out this form?
Please check: Builder   Owner   Other     Other: (if other, please indicate here)
 
Street Address of Site:

i.e. 911 Emergency ADDRESS
 
Legal Land Description
› Alberta legal land descriptions explained
Please check: NE   NW   SE   SW    

1/4 Sec    Twp    Rge    Meridian 
 
Lot/Block/Plan
Lot    Block    Plan
 
Current Mailing Address

Your current mailing address. Please include postal code.
 
Phone Numbers
Home    Mobile     Work    Other
 
Email:
 

- Building Information -

 
Plot Plan


Please send us your plan using the upload tool above. If you have any difficulty with this tool, email separately to D&S Enterprises, making sure to include your full name so we can match your plan to this form. FAX not available.

✭ We require a current plot plan showing all boundaries and building locations. The plot plan is required for locates (of buried facilities i.e. power cables, data cables, gas lines etc) and in order comply with County/Municipal District requirements for compliant designs.
 
House Size
Sq. Feet   Sq. Feet  
 
Occupants

How many people will live in this building?

 
Bedrooms TOTAL:
Total # of Bedrooms (include any additions below)
 
Bathrooms TOTAL:
Total # of Bathrooms (include any additions below)
 
 
Water softener?   Yes   No   Iron filter?   Yes   No   Reverse osmosis?   Yes   No   Garburator?   Yes   No  

Additional high water use fixtures?
i.e. Jet tub, hot tub, pool, steam showers, multi-head showers

If yes, please indicate...

Size of tub/s     Pool Dimension

Steam shower / Multi head shower:
# of standard heads    # of body sprays    # of rain cans
 
Water Source
Well   Cistern   Municipal  
 
Other Buildings
 
Home Based Business:

Hairdresser, dog grooming, catering, bed & breakfast, day care
 
Hobbies:

i.e. Beer/wine making, canning
 
Lifestyle:

i.e. Entertaining, catering, gourmet cooking = excess oil and grease. Maid Service = use of high strength cleaners.
 
Location of Neighbouring Wells:
 
Any Covenants or Easements:

ie. Water, sewer, power, cable, fiber optic, gas, phone, underground tanks, other pipelines, rights of ways
 

- Future Building Plans (additions, future development) -

 
Additions
Sq. Feet   Sq. Feet  
Future Additional Bedrooms:
Total # of Future Additional Bedrooms
 
Future Additional Bathrooms:
Total # of Future Additional Bathrooms
 
 
Water softener?   Yes   No   Iron filter?   Yes   No   Reverse osmosis?   Yes   No   Garburator?   Yes   No  

Additional high water use fixtures?
i.e. Jet tub, hot tub, pool, steam showers, multi-head showers

If yes, please indicate...

Size of tub/s     Pool Dimension

Steam shower / Multi head shower:
# of standard heads    # of body sprays    # of rain cans
 
Future Home Based Business:

Hairdresser, dog grooming, catering, bed & breakfast, day care
 

- Septic System Restrictions/Terms -

Septic System Restrictions: All or any water treatment systems cannot flow into the septic system. These include water softeners, iron filters, reverse osmosis systems etc. No floor drains or weeping tile systems or basement sumps are allowed to drain into the septic system.

Terms - septic system design:

  • The design process may begin after this form is filled out. A proper legal land description and a plot plan is required. If a plot plan is not available, please provide a rough draft drawing with dimensions (and position of well, house, barn, garage etc). This information is REQUIRED in order to submit mandatory locates for underground utilities.
  • We will review this form and contact you with a design estimate prior to commencing any work.
  • Design begins after soil evaluation.
  • The design is only valid after full payment is received by the designer. Using the design without full payment is fraudulent.
Agreement
Yes, I agree




_____________________________________ Signature

By ticking the box above, you are acknowledging that you are aware of the Septic System Restrictions and the Terms of the the Septic System Design, including payment terms. You agree that to the best of your knowledge, no other water use devices will be included on the premises as outlined in the restrictions and that you are responsible for the information you have provided above and that our system design will be based on the information you have supplied. You further agree that you will provide any of the above documents as required.

 
Do you have any comments or questions?
 
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