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* 1. Where is your home or building located? Please note, Name, e-mail address, and phone number are optional.

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* 2. Does the building have a basement?

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* 3. Does the building have a crawl space?

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* 4. Does the building have a sump pump (water from the basement is pumped outside)?

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* 5. Does the building have any of the following sewer back up protection devices?

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* 6. Has your basement flooded in the past?

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* 7. If Yes, where did the water or sewage come from? (Check all that apply)

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* 8. Please list approximate flooding dates and how deep the water or sewage was from the basement floor.

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* 9. If your basement sewer backs up does it only happen when it is raining?

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* 10. If you have experienced basement sewer back ups in the past do you have an idea what caused the problem?

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* 11. How often do you have your private sanitary service cleaned/rodded?

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