Sanitary Survey Checklist
Date
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Survey Conducted by
First Name
Last Name
Is the safe yield sufficient to meet current and future demands?
Yes
No
Is the quantity of the source sustainable?
Yes
No
Does the PWS have an operational master meter?
Yes
No
How many service connections are there?
Does the PWS meter all service connections?
Yes
No
Does the PWS have interconnections with neighboring PWSs or a contingency plan for water outages?
Yes
No
Does the PWS have redundant sources?
Yes
No
Does the PWS have a smooth-nozzle raw water tap and treated water tap for each well?
Yes
No
Is the well site subject to flooding?
Yes
No
Is a driller's log available?
Yes
No
Does the sanitary seal meet primacy agency standards?
Yes
No
Is the well pit checked and cleaned as part of regular maintenance?
Yes
No
Have the well casing and screens been inspected?
Yes
No
Is the site subject to flooding?
Yes
No
Is the spring box properly constructed?
Yes
No
Is the safe yield sufficient to meet current and future demands?
Yes
No
If permits are required, is the facility operating within the limits?
Yes
No
Is there an emergency spill response plan?
Yes
No
Is the area around the intake restricted?
Yes
No
Is the area around the intake restricted and clearly marked?
Yes
No
Is the actual capacity of the pumping facility adequate to meet the demand?
Yes
No
Has the water system identified and implemented techniques and practices for its sustainability?
Yes
No
Is there a drought response plan?
Yes
No
Additional Notes
Submit
Should be Empty: